"Intergenerational Trauma in Risk Factors/Health Outcomes of African Americans" by Alexis Bennett

The Role of Intergenerational Trauma in Risk Factors and Health Outcomes of African Americans: An Analysis of the Public Health Literature

Alexis Bennett, William Patterson University

Abstract: Intergenerational trauma is a dynamic concept that has been a focus of many studies in the 20th and 21st centuries. Intergenerational trauma is not only a ubiquitous reality in American society, but it is also a significant factor in public health issues. Intergenerational trauma can be understood as significant adverse events experienced by individuals that have such a profound impact, offspring of the individuals face struggles with the post-traumatized state of their parents. Studies have examined intergenerational trauma among various populations including Holocaust survivors, Japanese American internment camp survivors, Armenian refugees, and more recently, African Americans. However, the role intergenerational trauma plays in public health outcomes among African Americans has been given less attention. This research paper will present findings from a scoping literature review focused on how the concept of intergenerational trauma is currently being used in the public health field to understand and address health issues among African Americans. Along with the concept of intergenerational trauma, there are other closely related issues that contribute to how past traumatic experiences may impact the public’s health, including historical trauma and various forms of racism. Recommendations for further research on intergenerational trauma, a vital part of advancing the health and wellbeing of this oppressed population, will be shared. In order to form “a more perfect Union,” the lives of all Americans must be valued and protected. In finding ways to improve the health of our marginalized citizens, America can take an honorable step towards that ideal Union.



The concept of intergenerational trauma is complex and has been defined in a variety of ways. Intergenerational trauma can be understood as significant adverse events experienced by individuals that have a profound impact on their offspring, who consequently face struggles with the post-traumatized state of their parents (Yehuda & Lehrner, 2018). Farquharson & Thornton (2020) explain intergenerational trauma as how exposure to a traumatic event can be transferred from generation to generation and how it can impact how individuals in a community and/or how families heal and cope with trauma. These definitions are closely aligned in identifying the root of intergenerational trauma to be the experiencing of a traumatic event and only slightly differ in describing the span of impact.

These definitions lay the foundation for the notion that intergenerational trauma is not only a ubiquitous reality in American society, but that it could also be a significant factor in public health issues. This research paper is concerned with exploring the concept of intergenerational trauma with a focus on the African American community. It explores some of the key contributors to intergenerational trauma in the African American community and addresses how intergenerational trauma is related to health outcomes, including mental and physical health and risk factors.

1. Causes of Intergenerational Trauma Among African Americans

1.1 Historical Trauma

Historical trauma describes critically severe events experienced by a particular group of people (ethnic, cultural, racial, etc.) that causes suffering to the descendants of the group (Bryant-Davis et al., 2017). Very similarly, the term cultural trauma has been described as when members of a group’s consciousness, memories, and future identity have been deeply and indelibly impacted through experiencing an abhorrent event (J. C. Alexander, 2012). There have been many studies of historical and cultural trauma focused on Jewish holocaust survivors and their descendants, Indigenous populations, survivors of Japanese-American internment camps and their descendants, and increasingly within the past two decades, African Americans (Mohatt et al., 2014).

The Tuskegee Syphilis Study, beginning in 1932, is an infamous example of historical and cultural trauma experienced by African Americans, one that deeply scarred generations of African American families and broke their already compromised trust in the American medical system. This study shaped generations of African Americans’ perceptions of and interactions with healthcare professionals and contemporary medicine and research, ultimately contributing to health disparities (Lincoln et al., 2021; Sacks et al., 2021). For example, in a study examining the barriers to participation for African Americans in Alzheimer’s clinical research, Lincoln et al. (2021) found that mistrust of physicians and researchers, mistrust of white researchers/clinicians, and historical mistreatment were the most frequently mentioned barriers to their own and other African Americans participation in research. Health research can provide information on the effectiveness of medical interventions, lead to the development of new therapies and medical breakthroughs, improve use of drugs, diagnostics and vaccines, and result in major improvements in overall public health. African Americans are disproportionately impacted by Alzheimer’s Disease, therefore, this study and others like it raise valid questions regarding the effect of historical and cultural trauma on reluctance to participate in clinical studies and/or seek health care and how this may be related to health outcomes and disparities (Lincoln et al., 2021).

Slavery is the most significant example of historical and cultural trauma that still plagues African Americans to this day. Among its many facets and detrimental consequences, recent research has explored how this particular trauma has affected African American women’s decision-making regarding breastfeeding their infants. Breastfeeding has a plethora of benefits for both infants and their mothers, including reduced risk of sudden infant death syndrome (SIDS), obesity, asthma, and Type 1 diabetes in infants, as well as reduced risk of breast cancer, ovarian cancer, Type 2 diabetes, and high blood pressure in mothers (Petersen, 2018). In a qualitative study examining the various influences on African American women’s infant-feeding practices, participants cited aspects of African American history, including wet nursing, a practice where enslaved black women who were lactating were forced to breastfeed their owner’s children, which simultaneously limited their ability to provide for and nurture their own children, as a negative influential factor in their decision to breastfeed (DeVane-Johnson et al., 2018; Green et al., 2021). Historical and cultural trauma experienced by African Americans has deeply wounded generations of this ethnic group, firmly shaping the ideologies, perceptions, beliefs, and behaviors within the community as well as influencing both their physical and mental health outcomes.

1.2 Racism

Racism, “the systemic subordination of members of targeted racial groups who have relatively little social power in the United States . . . supported by the actions of individuals, cultural norms and values, and the institutional structures and practices of society”, is a significant contributor to intergenerational trauma, affecting African Americans in every aspect of their life (Adams et al., 2016). Racism in American society takes place in many forms, including structural racism and vicarious racism. In recent decades, public health and medical researchers have examined its relationship to various health outcomes.

1.2.1 Structural Racism

Structural Racism refers to the macro-level mechanisms, societal systems, and institutional practices that result in widespread racial inequality and adverse conditions for minorities, especially African Americans (Yearby, 2020). The force of structural racism in America is so robust, it is believed that even if discrimination was eliminated completely at the interpersonal level, racial disparities would most likely persist (Gee & Ford, 2011). Generations of African Americans have had to endure different forms of structural racism. Each generation has experienced how it debilitates almost every aspect of their life because it powerfully shapes the “discriminatory practices and policies of institutions and actions of individuals” (Krieger, 2021). Actors of structural racism, such as mass incarceration, state-perpetrated violence, and housing segregation, are linked to intergenerational trauma as they restrict African Americans’ abilities to raise their families, attain opportunities and resources, maintain a decent living, and have freedom (M. Alexander, 2012; Harrell, 2000; Zwi et al., 2002).

A premier example of structural racism in the 20th century is redlining. Redlining describes discriminatory provisions of bank lending and consumer services against economically disadvantaged and minority neighborhoods, which has powerfully influenced the flow of mortgage and property investment since the 1930s (Dreier, 1991). The practice originated when FDR’s government developed color-coded maps for his loan programs after the great depression, where green represented predominantly white neighborhoods and red represented predominantly black neighborhoods (SHAC, 2020). It was much harder to get a loan in red neighborhoods compared to green neighborhoods and for a period of time (1934-1968) white families were given 98% of the loans from the Federal Housing Administration. While white families were able to build generational wealth, black families were unable to do so, contributing to intergenerational poverty (SHAC, 2020). The housing segregation stemming from this practice has led to significant racial differences in socioeconomic status. Predominantly black neighborhoods have faced lower quality government services and resources and residents have had limited access to educational and employment opportunities (Popescu et al., 2018). Familial socioeconomic resources have a strong correlation to educational outcomes, since families of higher socioeconomic status are able to afford childcare, private tutoring, advanced technology, and other resources that allow their children to better develop social-emotional and academic skills (StanfordCEPA, 2018). So, not only do African Americans have to endure their present-day reality of structural racism, but they also have to deal with the accumulation of trauma experienced by their ancestors due to fundamental inequities in the structure of the American system.

Research in public health has elucidated how structural racism is deeply rooted in inequities in the social determinants of health: health and healthcare, education, social and community context, economic stability, and neighborhood and built environment; these determinants are upstream, macro-level factors recognized by the government as being responsible for racial health disparities (Bailey et al., 2017, 2021; Healthy People 2020, 2013; Yearby, 2020). An example of this is seen in research done by Krieger et al. (2020), who identified historical redlining as a potential structural determinant of present-day risk of preterm birth in New York City.

1.2.2 Vicarious Racism

Vicarious racism has been defined as instances where persons of color are indirectly exposed to or experience racism that is directly targeted at other people of color (friends, family, or even strangers) in their environment; this type of racism can be experienced through learning about or observing friends’ or familial encounters with racism or racist events (Harrell, 2000; Truong et al., 2016). The major advancements in technology and the popularity of social media have made way for racist acts and events happening all around the country to be viewed by people, even young children. As a result, it is probable that all African Americans have had to endure some sort of racism. Experiences of vicarious racism can be a contributing factor to intergenerational trauma (Carter et al., 2013; Kirkinis et al., 2021). Researchers have found that exposure to vicarious racism is commonly associated with poorer child and socioemotional health outcomes; associations between parental discrimination (discrimination experienced by one’s parent/s) and child internalizing issues (e.g., being nervous or withdrawn, feeling afraid, lonely, or sad, concentration problems, and eating more or less than usual) (Bécares et al., 2015; Espinoza et al., 2016; Heard-Garris et al., 2018).

The community-level trauma endured by African Americans due to police violence is another form of vicarious racism. The well-known history of state-backed police brutality against the African American community (i.e. Rodney King, Selma-to-Montgomery Marches, Trayvon Martin, etc.), perpetuates vicarious racism and contributes to intergenerational trauma. The consequences for generations of African Americans include internalized oppression, suicidality, post-traumatic stress disorder (PTSD), psychological distress, depression, and substance dependence (Kirkinis et al., 2021). Martz et al. (2019) found indications that stress related to experiencing vicarious racism is significantly associated with increased disease activity (severity of the disease) among African American women with systemic lupus erythematosus (SLE) and can have damaging effects on their physical health. Vicarious racism is a very important determinant in the severity of intergenerational trauma experienced by people in the African American community, one that deserves more attention in public health literature and research.

2. Intergenerational Trauma in Public Health Literature

Although intergenerational trauma in health literature is very complex, right down to its very definition, its more recent emergence in literature with a focus on African Americans is rather cohesive. All of the literature, whether directly or indirectly, acknowledges racism as the root of health inequities and psychological distress for this marginalized group. Much of the literature on intergenerational trauma consists of qualitative research and analyses that look to various aspects of the African American experience in the past few centuries to determine how their collective experiences have culminated in intergenerational trauma. There are also many quantitative studies framed by theories and conceptual frameworks that suggest intergenerational trauma is not only a health outcome in its own right, but also a foundation from which many other adverse health outcomes manifest. There is a current focus in the public health literature on intergenerational trauma as an explanatory concept for the many adverse health outcomes that African Americans experience disproportionately.

Research Question

My research focused on the concept of intergenerational trauma in public health research and practice. My research question is as follows: What is the role of intergenerational trauma in the health risk factors and health outcomes of African Americans in the public health literature?

Research Design

A scoping literature review focused on the public health literature was utilized to effectively examine the concept of intergenerational trauma and its related health impacts on the African American population. A scoping literature review is a tool used to gauge the nature and exploration of a topic in literature and to provide a synopsis of its focus (Grant & Booth, 2009; Munn et al., 2018).

Data Collection

Medline via ProQuest was searched during February 2022 and the search was restricted to peer-reviewed publications published between the years 2000 and 2022. Search terms included “intergenerational trauma”, “African Americans”, “generational trauma”, “health outcomes”, and “risk factors”. Search terms were searched on Medline via ProQuest and the search was limited to articles in English. The articles were vetted to ensure they met the keyword, date, and principal criteria related to intergenerational trauma, health outcomes, and risk factors among African Americans.

Data Management and Analysis

Abstracts collected from the Medline search were saved to a Mendeley database. A PRISMA flow diagram was used to record the number of articles at each stage of the screening and eligibility review (The Joanna Briggs Institute, 2015). The initial search on Medline yielded 74 articles and 2 additional articles were identified through other sources. Any articles that did not fit the basic inclusion criteria of the study and any duplicates were removed based on a screening of the title and abstract. Inclusion criteria included the following: primary research, studies that identified key findings that related to the role of intergenerational trauma in health risk factors and health outcomes among African Americans, and studies with a majority African American population focus. 47 articles were excluded at this step. A post-screening eligibility review was conducted on full-text articles and 20 studies were deemed eligible to be included in the final review, following the PRISMA template.

Scoping Literature Review Findings

How is intergenerational trauma experienced by African Americans represented in the public health literature?

Although the term intergenerational trauma is not always explicitly named or measured in the public health literature, it is increasingly being conceptualized as a relevant factor contributing to adverse health outcomes for African Americans. The majority of the studies do this by examining the adverse childhood experiences (ACEs) of parents or children. Types of ACEs include witnessing intimate partner violence, parental substance use, parental divorce, abuse, and neglect. Several studies utilized the Adverse Childhood Experiences survey, developed by Felitti et al. (1998), to investigate ACEs. Although consisting of a similar definition as ACEs, childhood trauma is categorized separately in the literature. For example, Adgent et al. (2019) examined the impact of maternal childhood and lifetime trauma among pregnant women on infant bronchiolitis.

Despite the pervasiveness of the adverse childhood experiences framework in the literature, several studies look at intergenerational trauma through other lenses, examining structural factors and other forms of trauma. Gavin et al. (2022) concluded that racial discrimination, a facet of intergenerational trauma, may contribute to PTSD and may in turn perpetuate disparities in cardiovascular-related conditions. Ali et al. (2022) examined how restrictive funding shapes access to inadequate mental health services that lack consideration of multilevel trauma and broader structural oppression. Johnson et al.'s (2021) findings indicated that well established social and economic factors, and exploitive practices experienced during slavery act as current racial traumas, discouraging breastfeeding, and depriving black infants of the psychological, developmental, and physical benefits of this health-promoting practice.

Intergenerational trauma is not only being looked at as a concept that perpetuates adverse health outcomes, but also one that contributes to risk factors for those health outcomes. For example, Egede et al. (2021) identified continued experiences of racism, residential segregation, violence, discrimination, and incarceration as contributors to stress, which is linked to many adverse health outcomes. Toledo-Corral et al. (2021) identified being Black as a predictive factor for perceived stress and depressive symptomology trends during pregnancy. Powers et al. (2020) acknowledged the role of critical health disparities that exist among African Americans and their high risk of exposure to traumatic events when concluding that maternal emotion dysregulation was significantly associated with greater PTSD symptoms in the child. Researchers used these findings to better understand the factors involved in the intergenerational transmission of trauma-related risk in children and indicated that these outcomes contribute to health disparities among African Americans (Powers et al., 2020). Researchers conceptualized intergenerational trauma within the different levels of the Social-Ecological Model, including at the micro-level (small systems like individuals and families), meso-level (medium systems like organizations and communities), and macro-level (large systems like societal conditions and public policy). Although difficult to measure directly, intergenerational trauma’s presence as an underlying contributing factor to adverse health outcomes is well established in the literature, influencing variables like ACEs and health risk factors, which are more clearly represented in the literature.

Which risk factors and health outcomes is intergenerational trauma being applied to?

Throughout the public health literature, the concept of intergenerational trauma among African Americans is applied to a wide variety of health risk factors, and both mental and physical health outcomes. Several studies directly examined health risk factors and behaviors, considering the influence of intergenerational trauma in both. Shin et al. (2021) indicated that ACE-exposed youth are more vulnerable to substance use and situate this finding within the context of intergenerational trauma, understanding that parental substance use is often associated with neglectful and abusive parenting practices. In a study of predominantly (93%) African American, urban, and low-income pregnant women, Jasthi et al. (2021) found that women who reported 6 or more ACEs were almost four times as likely to use marijuana during pregnancy, indicating that women with a history of trauma and adversity can be particularly vulnerable. These researchers cited findings from Forray & Foster (2015) to outline the connection between perinatal substance use disorders and inconsistent prenatal care and problematic early parent-infant interactions, stating that this can compound the adverse effects of prenatal drug exposure (i.e. low birth weight, placental abruption). Quinn et al. (2021) cited structural and institutional racism as factors that influence disparities in the development of illnesses, such as depression, that are not traditionally linked to African American health outcomes. The same study also acknowledged the roles that both mass incarceration and drug infestation (i.e., African American, low-income public housing communities being ground zero for the crack epidemic) play in public housing communities and systems of inequality that can influence different behavioral problems and substance misuse among African American youth. The influence of mass incarceration has disrupted African American family structures, exposing a mechanism through which intergenerational trauma is transmitted (Quinn et al., 2021).

Almost all of the articles examined in the scoping literature review discuss mental health outcomes and how intergenerational trauma drives these outcomes. For example, Caceres et al. (2020) found that experiencing traumatic events throughout life is associated with worse mental health and higher stress overload, both of which had a direct negative effect on the BMIs of African American women enrolled in the Intergenerational Impact of Genetic and Psychological Factors on Blood Pressure (InterGEN) Study.

Consideration of the parent-child dyad, particularly the mother-child dyad, is pervasive throughout the literature. Paredes et al. (2001) found that maternal childhood experiences of sexual abuse, family-of-origin problems, and inconsistent relationships with caregivers is related to increased child psychological symptomatology. Powers et al. (2020) identified from their study that maternal emotion dysregulation is significantly associated with greater PTSD symptoms in the child. A smaller number of articles in the literature look at physical health outcomes. Gavin et al. (2022) outlined how racial discrimination can contribute to PTSD, noting that this can arise from acute or chronic traumatic experiences vicariously experienced and/or learned about by the afflicted person, which could subsequently lead to increased risk of cardiovascular events and cardiovascular-related conditions. Participants in Egede et al. (2021) study revealed that they possess a sense of hopelessness that results from the social factors (i.e., racism and discrimination) dominating their lives. In this qualitative study, the participants themselves link these social factors to both risk factors and health outcomes, indicating that the resulting stress and trauma they suffer from results in poor health and disability (Egede et al., 2021).

A few articles also focus on pregnant women, bringing to light how intergenerational trauma can come into play before a child is even born. Jasthi et al. (2021) established a strong association between ACEs and suicidal thoughts during pregnancy, pointing out that high exposure to childhood adversity is associated with adverse mental health outcomes and perinatal substance use, which can negatively impact the fetus/infant. Hartzell et al. (2020) found heightened levels of PTSD, depression, and trauma exposure in a sample of low-income pregnant African American women, correlations between socioeconomic status (SES) and increased levels of PTSD and depression symptoms, and a positive association between maternal PTSD and parenting stress. Hartzell et al. (2020) stated that these findings should be viewed in the context of established mechanisms of transmission of traumatic stress.

What kinds of recommendations is the literature making to resolve intergenerational trauma among African Americans?

In examining the recommendations throughout the literature, intervention strategies are more common than prevention strategies, however, many articles make recommendations that could fit under both categories. When discussing potential prevention efforts, studies typically pointed to the macro- and meso-levels of the SEM as the main areas for change, as seen in recommendations for trauma-informed prevention programs and evidence-based, trauma-informed care (Caceres et al., 2020; Shin et al., 2021). Ali et al. (2022) identified opportunities in formulating localized and social justice-driven changes through targeting meso-level factors, like restrictive mental health funding in the US South and HIV and mental health stigma, which they view as structural and modifiable. They further suggested that organizations and community groups enhance community engagement in mental health and wellness services and combat HIV and mental health stigma through capacity building connected to mobilization and advocacy for structural change. Gavin et al. (2022) urged that public health efforts aiming to mitigate racial disparities in cardiovascular-related conditions address structural factors, like racial discrimination, that disrupt one's typical life trajectory and their capacity to maintain good health by changing institutional policies and societal norms.

In terms of interventions, Adgent et al. (2019) suggested the development of strategies that aim to modify the lasting effects of childhood trauma prior to or during pregnancy as a way to lessen the burden of bronchiolitis during infancy. Jasthi et al. (2021) recommended that healthcare providers screen for adversity and current symptoms to get a more comprehensive understanding of patient health and to reduce health risks for women and infants during the perinatal period. The study also recommended informing patients about the associations between one’s history and present functioning and highlighted the need for collaborative referrals to specialized services when necessary. A number of studies recommended trauma-informed care, like Caceres et al. (2020) who suggested that in order to better serve African American women, clinicians should be educated about the negative health effects of trauma and relevant psychosocial factors for this particular group. Powers et al. (2020) acknowledged the need for identifying relevant barriers to health-promoting behaviors and discovering ways to minimize those barriers for African American women, stating that this is essential in improving care for them.


This scoping literature review examined research on intergenerational trauma among African American populations. This is a growing literature within the public health field that is focused on a diverse set of risk factors and health outcomes that are rooted in the concept. The literature investigates the influence of intergenerational trauma via qualitative and quantitative studies, providing a comprehensive evidence base for the impacts of this expansive concept. I find that studies tend to measure adverse childhood experiences (ACEs) in order to conceptualize the presence and influence of intergenerational trauma on health risk factors, behaviors, and outcomes. This tactic potentially limits researchers’ ability to fully understand the effects of intergenerational trauma beyond the established definition of ACEs in the public health literature. The maternal-child dyad is a common focus of studies on intergenerational trauma, highlighting the notion that mother-child interactions are considered a significant transmission pathway for intergenerational trauma. African American women (mostly mothers) are the focus of over 50% of the studies I identified. There is a need to examine other subpopulations in the African American community (i.e. African American fathers, LGBTQ+, first-generation African Americans, mixed-race African Americans). The nuanced experiences of these subgroups can widen the scope of knowledge on intergenerational trauma, transmission pathways, and associated health outcomes.

Considering the clear role of structural and historical factors in the perpetuation of intergenerational trauma among African Americans, future research would benefit from considering factors like structural racism, vicarious racism, historical trauma, socioeconomic status, access to health services, and specific historical events (i.e. 80s crack epidemic), as factors like these have been known to mediate experiences of intergenerational trauma. ACEs, PTSD, and depression questionnaires, surveys, and checklists were frequently used in the studies, however, it seems as though there is a lack of established ways to solely measure intergenerational trauma. The African American Historical Trauma (AAHT) questionnaire was developed to measure the extent of historical trauma that African Americans are currently experiencing and how it is affecting their daily life (Williams-Washington & Mills, 2018). The questionnaire examines the correlations between discrimination, memories of past generations' degrading experiences, and present levels of historical trauma (Williams-Washington & Mills, 2018). Researchers should expand this measure and/or develop new measures like this one to assess other forms of trauma experienced by African Americans to accurately evaluate the numerous dimensions of this issue.

Intergenerational trauma can be looked at in a variety of ways: as a health outcome, a risk factor, a mediating factor, and a conceptual framework. Intergenerational trauma is a complex, emerging topic in public health literature that has the potential to greatly inform public health programs, interventions, and prevention strategies. Understanding the significant influence of intergenerational trauma on various facets of health, the topic warrants research dedicated solely to it and its health effects, instead of it just being examined as an underlying factor.

Consistent use of established measures, like the AAHT questionnaire, and the development of new, culturally tailored measures can help to advance research on the subject and further establish intergenerational trauma as a prominent risk factor for adverse health outcomes. Practitioners working with African American patients of any age should consider pre-screening their patients for mental health issues as well as gather information on their experiences of and exposure to racism and historical trauma at its different levels. Practitioners should also be able to provide referrals for culturally appropriate and trauma-informed mental health services for this population, whether or not the patient is exhibiting signs of mental illness, to prevent any health issues from manifesting. In addition, programs and initiatives directed at African American expectant mothers, particularly those with identifiable ACEs, should be implemented in order to reduce the chances of transmitting trauma to their children.

As for the health care system as a whole, health equity needs to be placed at the forefront to reduce health disparities and promote good health and well-being, especially among neglected and marginalized populations in the US. Future and existing healthcare workers should be educated on the concept of intergenerational trauma and be trained on how to appropriately manage and hopefully mitigate patients’ health conditions in relation to it and make effective recommendations for those who may have experienced it.

Intergenerational trauma is a relevant health concept that warrants thorough research and understanding to improve health outcomes and promote equity in public health and healthcare. African Americans are strongly susceptible to experiencing intergenerational trauma, placing another disadvantage on this already strained group. Healthcare systems and policymakers must acknowledge this burden on the health of African Americans and take proactive measures to lessen the negative impacts and occurrence of intergenerational trauma.


The concept of intergenerational trauma in health literature and its correlation to health outcomes among African Americans is still fairly new, meaning the potential for discovery and new perspectives is ample. A significant gap in the literature can be observed in the lack of studies examining factors like historical trauma, structural racism, vicarious racism, socioeconomic status, access to health services, specific historical events, and housing in/stability, and the influence of these factors in the perpetuation of intergenerational trauma. Considering that African Americans are not a monolith, there are a lot more ways in which the effects of this concept can be studied with regard to this community. The hardships that many African Americans face are not experienced in isolation and it is important that any mediating factors impeding good health among this group are properly identified and addressed.


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