Advertisement

Journal of Behavioral Medicine

, Volume 42, Issue 4, pp 724–740 | Cite as

What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review

  • Megan RanneyEmail author
  • Rebecca Karb
  • Peter Ehrlich
  • Kira Bromwich
  • Rebecca Cunningham
  • Rinad S. Beidas
  • for the FACTS Consortium
Article

Abstract

The long-term consequences of exposure to firearm injury—including suicide, assault, and mass shootings—on children’s mental and physical health is unknown. Using PRISMA-ScR guidelines, we conducted a scoping review of four databases (PubMed, Scopus, PsychINFO, and CJ abstract) between January 1, 1985 and April 2, 2018 for articles describing long-term outcomes of child or adolescent firearm injury exposure (n = 3582). Among included studies (n = 31), most used retrospective cohorts or cross-sectional studies to describe the correlation between firearm injury and post-traumatic stress. A disproportionate number of studies examined the effect of mass shootings, although few of these studies were conducted in the United States and none described the impact of social media. Despite methodologic limitations, youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury. Evidence is lacking on best practices for prevention of mental health and behavioral sequelae among youth exposed to firearm injury. Future research should use rigorous methods to identify prevalence, correlates, and intervention strategies for these at-risk youth.

Keywords

Firearm Suicide Mass shooting Accidental injury Community violence Post-traumatic stress 

Notes

Acknowledgements

The authors wish to acknowledge Lynn Massey for assistance with the literature search, organizing data abstraction, and manuscript preparation. We would also like to acknowledge Gurpreet Kaur Rana, Informationist at the Taubman Health Sciences Library, University of Michigan, for creating the search strategies for the scoping review; and Zahra Asghar for her assistance with initial literature reviews.

Funding

This review was funded by NIH/NICHD 1R24HD087149-01A1. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies.

Compliance with ethical standards

Conflict of interest

Megan Ranney, Rebecca Karb, Peter Ehrlich, Kira Bromwich, Rebecca Cunningham, Rinad S. Beidas, for the FACTS Consortium declares that they have no conflict of interest.

Human and animal rights and Informed Consent

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. Affinati, S., Patton, D., Hansen, L., Ranney, M., Christmas, A. B., Violano, P., et al. (2016). Hospital-based violence intervention programs targeting adult populations: An Eastern Association for the Surgery of Trauma evidence-based review. Trauma Surgery & Acute Care Open, 1, e000024.CrossRefGoogle Scholar
  2. Alcorn, T. (2017). Trends in research publications about gun violence in the United States, 1960 to 2014. JAMA Internal Medicine, 177, 124–126.CrossRefGoogle Scholar
  3. Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8, 19–32.CrossRefGoogle Scholar
  4. Bair-Merritt, M. H., Blackstone, M., & Feudtner, C. (2006). Physical health outcomes of childhood exposure to intimate partner violence: A systematic review. Pediatrics, 117, e278–e290.CrossRefGoogle Scholar
  5. Barthel, M., Shearer, E., Gottfried, J., & Mitchell, A. (2015). The evolving role of news on Twitter and Facebook. Pew Research Center, 14, 1–18.Google Scholar
  6. Benson, J. E., & Elder, G. H., Jr. (2011). Young adult identities and their pathways: A developmental and life course model. Developmental Psychology, 47, 1646.CrossRefGoogle Scholar
  7. Bergman, B., Ponzer, S., & Brismar, B. (1996). Criminality and morbidity in young victims of firearm injuries: A follow-up study. Annals of the New York Academy of Sciences, 794, 334–335.CrossRefGoogle Scholar
  8. Bergström, A., & Jervelycke Belfrage, M. (2018). News in social media: Incidental consumption and the role of opinion leaders. Digital Journalism, 6, 583–598.CrossRefGoogle Scholar
  9. Betz, M. E., Ranney, M. L., & Wintemute, G. J. (2016). Frozen funding on firearm research:“Doing nothing is no longer an acceptable solution”. Western Journal of Emergency Medicine, 17, 91.CrossRefGoogle Scholar
  10. Boynton-Jarrett, R., Ryan, L. M., Berkman, L. F., & Wright, R. J. (2008). Cumulative violence exposure and self-rated health: Longitudinal study of adolescents in the United States. Pediatrics, 122, 961–970.  https://doi.org/10.1542/peds.2007-3063 CrossRefGoogle Scholar
  11. Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Schweers, J., Roth, C., et al. (1993a). Psychiatric sequelae to the loss of an adolescent peer to suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 509–517.CrossRefGoogle Scholar
  12. Brent, D. A., Perper, J., Moritz, G., Friend, A., Schweers, J., Allman, C., et al. (1993b). Adolescent witnesses to a peer suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 1184–1188.CrossRefGoogle Scholar
  13. Bugge, I., Dyb, G., Stensland, S. Ø., Ekeberg, Ø., Wentzel-Larsen, T., & Diseth, T. H. (2015). Physical injury and posttraumatic stress reactions. A study of the survivors of the 2011 shooting massacre on Utøya Island, Norway. Journal of Psychosomatic Research, 79, 384–390.CrossRefGoogle Scholar
  14. Carter, P. M., Cook, L. J., Macy, M. L., Zonfrillo, M. R., Stanley, R. M., Chamberlain, J. M., et al. (2017). Individual and neighborhood characteristics of children seeking emergency department care for firearm injuries within the PECARN Network. Academic Emergency Medicine, 24, 803–813.CrossRefGoogle Scholar
  15. Carter, P. M., Walton, M. A., Roehler, D. R., Goldstick, J., Zimmerman, M. A., Blow, F. C., et al. (2015). Firearm violence among high-risk emergency department youth after an assault injury. Pediatrics, 135, 805–815.  https://doi.org/10.1542/peds.2014-3572 CrossRefGoogle Scholar
  16. Center for Disease Control and Prevention, C. (2014). Web-based injury statistics query and reporting systems: Fatal Injury Data (WISQARS). Retrieved from https://www.cdc.gov/injury/wisqars/fatal.html
  17. Cheng, T. L., Wright, J. L., Markakis, D., Copeland-Linder, N., & Menvielle, E. (2008). Randomized trial of a case management program for assault-injured youth: Impact on service utilization and risk for reinjury. Pediatric Emergency Care, 24, 130–136.CrossRefGoogle Scholar
  18. Chong, V. E., Lee, W. S., & Victorino, G. P. (2015). Neighborhood socioeconomic status is associated with violent reinjury. Journal of Surgical Research, 199, 177–182.CrossRefGoogle Scholar
  19. Chong, V. E., Smith, R., Garcia, A., Lee, W. S., Ashley, L., Marks, A., et al. (2015). Hospital-centered violence intervention programs: A cost-effectiveness analysis. The American Journal of Surgery, 209, 597–603.CrossRefGoogle Scholar
  20. Council, N. R. (2013). Priorities for research to reduce the threat of firearm-related violence. Washington: National Academies Press.Google Scholar
  21. Cunningham, R. M., Carter, P. M., Ranney, M., Zimmerman, M. A., Blow, F. C., Booth, B. M., et al. (2015). Violent reinjury and mortality among youth seeking emergency department care for assault-related injury: A 2-year prospective cohort study. JAMA Pediatrics, 169, 63–70.  https://doi.org/10.1001/jamapediatrics.2014.1900 CrossRefGoogle Scholar
  22. Cunningham, R. M., Walton, M. A., & Carter, P. M. (2018). The major causes of death in children and adolescents in the United States. New England Journal of Medicine, 379, 2468–2475.CrossRefGoogle Scholar
  23. David-Ferdon, C., Vivolo-Kantor, A. M., Dahlberg, L. L., Marshall, K. J., Rainford, N., & Hall, J. E. (2016). A comprehensive technical package for the prevention of youth violence and associated risk behaviors (pp. 1–61). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.CrossRefGoogle Scholar
  24. Davis, J. S., Pandya, R. K., Sola, J. E., Perez, E. A., Neville, H. L., & Schulman, C. I. (2013). Pediatric trauma recidivism in an urban cohort. Journal of Surgical Research, 182, 326–330.CrossRefGoogle Scholar
  25. DeWolfe, D. J. (2004). Mental health response to mass violence and terrorism: A training manual. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services.Google Scholar
  26. Dyb, G., Jensen, T., Glad, K. A., Nygaard, E., & Thoresen, S. (2014). Early outreach to survivors of the shootings in Norway on the 22nd of July 2011. European Journal of Psychotraumatology, 5, 23523.CrossRefGoogle Scholar
  27. Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2015). Prevalence of childhood exposure to violence, crime, and abuse: Results from the national survey of children’s exposure to violence. JAMA Pediatrics, 169, 746–754.CrossRefGoogle Scholar
  28. Follman, M., Aronsen, G., & Pan, D. (2018). US mass shootings, 1982–2018: Data from Mother Jones’ investigation. Mother Jones.Google Scholar
  29. Fowler, K. A., Dahlberg, L. L., Haileyesus, T., Gutierrez, C., & Bacon, S. (2017). Childhood firearm injuries in the United States. Pediatrics, 140, e20163486.CrossRefGoogle Scholar
  30. Fowler, P. J., Tompsett, C. J., Braciszewski, J. M., Jacques-Tiura, A. J., & Baltes, B. B. (2009). Community violence: A meta-analysis on the effect of exposure and mental health outcomes of children and adolescents. Development and Psychopathology, 21, 227–259.CrossRefGoogle Scholar
  31. Gibson, P. D., Ippolito, J. A., Shaath, M. K., Campbell, C. L., Fox, A. D., & Ahmed, I. (2016). Pediatric gunshot wound recidivism: Identification of at-risk youth. Journal of Trauma and Acute Care Surgery, 80, 877–883.CrossRefGoogle Scholar
  32. Gill, A. C. (2002). Risk factors for pediatric posttraumatic stress disorder after traumatic injury. Archives of Psychiatric Nursing, 16, 168–175.CrossRefGoogle Scholar
  33. Hafstad, G. S., Dyb, G., Jensen, T. K., Steinberg, A. M., & Pynoos, R. S. (2014). PTSD prevalence and symptom structure of DSM-5 criteria in adolescents and young adults surviving the 2011 shooting in Norway. Journal of Affective Disorders, 169, 40–46.CrossRefGoogle Scholar
  34. Hamrin, V. (1998). Psychiatric interviews with pediatric gunshot patients. Journal of Child and Adolescent Psychiatric Nursing, 11, 61–68.CrossRefGoogle Scholar
  35. Hamrin, V., Jonker, B., & Scahill, L. (2004). Acute stress disorder symptoms in gunshot-injured youth. Journal of Child and Adolescent Psychiatric Nursing, 17, 161–172.CrossRefGoogle Scholar
  36. Haravuori, H., Kiviruusu, O., Suomalainen, L., & Marttunen, M. (2016). An evaluation of ICD-11 posttraumatic stress disorder criteria in two samples of adolescents and young adults exposed to mass shootings: Factor analysis and comparisons to ICD-10 and DSM-IV. BMC Psychiatry, 16, 140.CrossRefGoogle Scholar
  37. Haravuori, H., Suomalainen, L., Berg, N., Kiviruusu, O., & Marttunen, M. (2011). Effects of media exposure on adolescents traumatized in a school shooting. Journal of Traumatic Stress, 24, 70–77.CrossRefGoogle Scholar
  38. Hawkins, N. A., McIntosh, D. N., Silver, R. C., & Holman, E. A. (2007). Early responses to school violence: A qualitative analysis of students’ and parents’ immediate reactions to the shootings at Columbine High School. Journal of Emotional Abuse, 4, 197–223.CrossRefGoogle Scholar
  39. Health, U. D. o., & Services, H. (2005). Terrorism and other public health emergencies: A reference guide for media. Washington, DC: Department of Health and Human Services.Google Scholar
  40. Heinze, J. E., Reischl, T. M., Bai, M., Roche, J. S., Morrel-Samuels, S., Cunningham, R. M., et al. (2016). A comprehensive prevention approach to reducing assault offenses and assault injuries among youth. Prevention Science, 17, 167–176.  https://doi.org/10.1007/s11121-015-0616-1 CrossRefGoogle Scholar
  41. Higgins, J., Sterne, J., Savović, J., Page, M., Hróbjartsson, A., Boutron, I., et al. (2016). A revised tool for assessing risk of bias in randomized trials. Cochrane Database Systematic Review, 10, 29–31.Google Scholar
  42. Jovanovic, T., Vance, L. A., Cross, D., Knight, A. K., Kilaru, V., Michopoulos, V., et al. (2017). Exposure to violence accelerates epigenetic aging in children. Scientific Reports, 7, 8962.CrossRefGoogle Scholar
  43. Karp, A. (2018). Estimating global civilian-held firearms numbers. Small Arms Survey.Google Scholar
  44. Kümpel, A. S., Karnowski, V., & Keyling, T. (2015). News sharing in social media: A review of current research on news sharing users, content, and networks. Social Media Society, 1, 2056305115610141.Google Scholar
  45. Levine, P. B., & McKnight, R. (2017). Firearms and accidental deaths: Evidence from the aftermath of the Sandy Hook school shooting. Science, 358, 1324–1328.CrossRefGoogle Scholar
  46. McGill, T., Self-Brown, S. R., Lai, B. S., Cowart, M., Tiwari, A., LeBlanc, M., et al. (2014). Effects of exposure to community violence and family violence on school functioning problems among urban youth: The potential mediating role of posttraumatic stress symptoms. Frontiers in Public Health, 2, 8.CrossRefGoogle Scholar
  47. Mercer, K. B., Orcutt, H. K., Quinn, J. F., Fitzgerald, C. A., Conneely, K. N., Barfield, R. T., et al. (2012). Acute and posttraumatic stress symptoms in a prospective gene × environment study of a university campus shooting. Archives of General Psychiatry, 69, 89–97.CrossRefGoogle Scholar
  48. Nader, K., Pynoos, R., Fairbanks, L., & Frederick, C. (1990). Children’s PTSD reactions one year after a sniper attack at their school. The American Journal of Psychiatry, 147, 1526.CrossRefGoogle Scholar
  49. Naghavi, M., Marczak, L. B., Kutz, M., Shackelford, K. A., Arora, M., Miller-Petrie, M., et al. (2018). Global mortality from firearms, 1990–2016. JAMA, 320, 792–814.CrossRefGoogle Scholar
  50. Netburn, D. (2018, November 10). The role of PTSD in mass shootings: Let’s separate myth from reality. Los Angeles Times. Retrieved from http://www.latimes.com/science/sciencenow/la-sci-sn-ptsd-mass-shootings-20181110-story.html
  51. Olfson, M., Wall, M., Wang, S., Crystal, S., Bridge, J. A., Liu, S.-M., & Blanco, C. (2018). Suicide after deliberate self-harm in adolescents and young adults. Pediatrics, 141, e20173517.CrossRefGoogle Scholar
  52. Omar, H. A. (1999). Adolescent violence as viewed by high school students. International Journal of Adolescent Medicine and Health, 11, 153–158.CrossRefGoogle Scholar
  53. Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid, A. (2016). Rayyan—A web and mobile app for systematic reviews. Systematic Reviews, 5, 210.CrossRefGoogle Scholar
  54. Ponzer, S., Bergman, B., Brismar, B., & Johansson, S. (1997). Accidental firearm injury in childhood—A predictor of social and medical outcome? European Journal of Emergency Medicine, 4, 125–129.CrossRefGoogle Scholar
  55. Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., et al. (1987a). Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry, 44, 1057–1063.CrossRefGoogle Scholar
  56. Pynoos, R. S., Nader, K., Frederick, C., Gonda, L., & Stuber, M. (1987b). Grief reactions in school age children following a sniper attack at school. Israel Journal of Psychiatry and Related Sciences, 24, 53–63.Google Scholar
  57. Rand Corporation. (2018). Mass shootings: Definitions and trends. Retrieved from https://www.rand.org/research/gun-policy/analysis/supplementary/mass-shootings.html
  58. Ranney, M. L., Fletcher, J., Alter, H., Barsotti, C., Bebarta, V. S., Betz, M. E., et al. (2017). A consensus-driven agenda for emergency medicine firearm injury prevention research. Annals of Emergency Medicine, 69, 227–240.  https://doi.org/10.1016/j.annemergmed.2016.08.454 CrossRefGoogle Scholar
  59. Roche, J. S., Clery, M. J., Carter, P. M., Dora-Laskey, A., Walton, M. A., Ngo, Q. M., et al. (2018). Tracking assault-injured, drug-using youth in longitudinal research: Follow-up methods. Academic Emergency Medicine, 25, 1204–1215.CrossRefGoogle Scholar
  60. Rowhani-Rahbar, A., Zatzick, D., Wang, J., Mills, B. M., Simonetti, J. A., Fan, M. D., et al. (2015). Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: A cohort study. Annals of Internal Medicine, 162, 492–500.CrossRefGoogle Scholar
  61. Samuelson, K. W., Wilson, C. K., Padrón, E., Lee, S., & Gavron, L. (2017). Maternal PTSD and children’s adjustment: Parenting stress and emotional availability as proposed mediators. Journal of Clinical Psychology, 73, 693–706.CrossRefGoogle Scholar
  62. Santiago, P. N., Ursano, R. J., Gray, C. L., Pynoos, R. S., Spiegel, D., Lewis-Fernandez, R., et al. (2013). A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: Intentional and non-intentional traumatic events. PLoS ONE, 8, e59236.CrossRefGoogle Scholar
  63. Schneider, S. J., Grilli, S. F., & Schneider, J. R. (2013). Evidence-based treatments for traumatized children and adolescents. Current Psychiatry Reports, 15, 332.CrossRefGoogle Scholar
  64. Schwarz, E. D., & Kowalski, J. M. (1991). Malignant memories: PTSD in children and adults after a school shooting. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 936–944.CrossRefGoogle Scholar
  65. Shih, R. A., Schell, T. L., Hambarsoomian, K., Marshall, G. N., & Belzberg, H. (2010). Prevalence of PTSD and major depression following trauma-center hospitalization. The Journal of Trauma, 69, 1560.CrossRefGoogle Scholar
  66. Shultz, J. M., Muschert, G. W., Dingwall, A., & Cohen, A. M. (2013). The Sandy Hook Elementary School shooting as tipping point: “This Time Is Different”. Disaster Health, 1, 65–73.CrossRefGoogle Scholar
  67. Slovak, K., & Singer, M. (2001). Gun violence exposure and trauma among rural youth. Violence and Victims, 16, 389.CrossRefGoogle Scholar
  68. Song, J. W., & Chung, K. C. (2010). Observational studies: Cohort and case-control studies. Plastic and Reconstructive Surgery, 126, 2234.CrossRefGoogle Scholar
  69. Spicer, R. S., & Miller, T. R. (2000). Suicide acts in 8 states: Incidence and case fatality rates by demographics and method. American Journal of Public Health, 90, 1885.CrossRefGoogle Scholar
  70. Srinivasan, S., Mannix, R., & Lee, L. K. (2014). Epidemiology of paediatric firearm injuries in the USA, 2001–2010. Archives of Disease in Childhood, 99, 331–335.CrossRefGoogle Scholar
  71. Stark, D. E., & Shah, N. H. (2017). Funding and publication of research on gun violence and other leading causes of death. JAMA, 317, 84–85.CrossRefGoogle Scholar
  72. Stene, L. E., & Dyb, G. (2015). Health service utilization after terrorism: A longitudinal study of survivors of the 2011 Utøya attack in Norway. BMC Health Services Research, 15, 158.CrossRefGoogle Scholar
  73. Stensland, S. Ø., Zwart, J.-A., Wentzel-Larsen, T., & Dyb, G. (2018). The headache of terror: A matched cohort study of adolescents from the Utøya and the HUNT Study. Neurology, 90, e111–e118.CrossRefGoogle Scholar
  74. Sterne, J. A., Hernán, M. A., Reeves, B. C., Savović, J., Berkman, N. D., Viswanathan, M., et al. (2016). ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. BMJ, 355, i4919.CrossRefGoogle Scholar
  75. Suomalainen, L., Haravuori, H., Berg, N., Kiviruusu, O., & Marttunen, M. (2011). A controlled follow-up study of adolescents exposed to a school shooting—Psychological consequences after four months. European Psychiatry, 26, 490–497.CrossRefGoogle Scholar
  76. Talley, C. L., Campbell, B. T., Jenkins, D. H., Barnes, S. L., Sidwell, R. A., Timmerman, G., et al. (2018). Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I. Journal of the American College of Surgeons, 228, 198–206.CrossRefGoogle Scholar
  77. Tellez, M. G., Mackersie, R. C., Morabito, D., Shagoury, C., & Heye, C. (1995). Risks, costs, and the expected complication of re-injury. The American Journal of Surgery, 170, 660–664.CrossRefGoogle Scholar
  78. The National Institute of Mental Health. (2017). Strategic Research Priorities Overview. Transforming the understanding and treatment of mental illnesses. Retrieved from https://www.nimh.nih.gov/about/strategic-planning-reports/strategic-research-priorities/index.shtml
  79. Thoresen, S., Jensen, T. K., Wentzel-Larsen, T., & Dyb, G. (2016). Parents of terror victims. A longitudinal study of parental mental health following the 2011 terrorist attack on Utøya Island. Journal of Anxiety Disorders, 38, 47–54.CrossRefGoogle Scholar
  80. Walton, M. A., Chermack, S. T., Shope, J. T., Bingham, C. R., Zimmerman, M. A., Blow, F. C., et al. (2010). Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: A randomized controlled trial. JAMA, 304, 527–535.  https://doi.org/10.1001/jama.2010.1066 CrossRefGoogle Scholar
  81. Wanner, J. P. (2015). Development of a trauma-specific quality of life measurement. The Journal of Trauma and Acute Care Surgery, 79, 275.CrossRefGoogle Scholar
  82. Wise, A. E., & Delahanty, D. L. (2017). Parental factors associated with child post-traumatic stress following injury: A consideration of intervention targets. Frontiers in Psychology, 8, 1412.CrossRefGoogle Scholar
  83. Zatzick, D., Jurkovich, G., Rivara, F. P., Russo, J., Wagner, A., Wang, J., et al. (2013). A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Annals of Surgery, 257, 390.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Emergency Medicine, Alpert Medical SchoolBrown UniversityProvidenceUSA
  2. 2.Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceUSA
  3. 3.American Foundation for Firearm Injury Reduction in MedicineWilliamstownUSA
  4. 4.Department of Surgery, Section of Pediatric SurgeryUniversity of Michigan School of MedicineAnn ArborUSA
  5. 5.Department of Emergency MedicineUniversity of Michigan School of MedicineAnn ArborUSA
  6. 6.School of Public HealthUniversity of MichiganAnn ArborUSA
  7. 7.Department of Psychiatry, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  8. 8.Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  9. 9.Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations