Dominican Republic Research Articles

P020 GENDER AND CARDIOLOGY: EVALUATION OF DISCRIMINATION, HARASSMENT AND LABOR INEQUALITY IN THE DOMINICAN REPUBLIC

Introduction: Gender disparity has been a topic of increasing interest and controversy in recent years. In the United States, women represent only 12.6% of cardiologists, a figure that reflects persistent inequalities in this specialty and often leads women to dismiss it as a viable career option. In addition, salary disparity remains an obvious problem, with a trend that tends to favor the male sex. On the other hand, in Japan, female cardiologists face professional limitations due to family and domestic responsibilities that restrict their development and advancement in the profession. Objective: To analyze and understand the perceptions and experiences of discrimination, harassment and work obstacles among cardiologists in the Dominican Republic, with a focus on gender differences. Methods: An observational, descriptive and cross-sectional study was carried out, in which a sample was randomly selected from the directory of the Dominican Society of Cardiology. An online questionnaire was used to collect demographic and work-related information, as well as data on experiences of discrimination, harassment and professional obstacles. Results: A sample of 51 patients was obtained, with an average age of 47.8 years, of whom 56.9% were women. Thirty-six.4% of women reported experiencing discrimination, compared with 13.8% of men. In terms of employment barriers, 62.1% of men reported obstacles related to remuneration, despite having higher monthly earnings compared to women. Of the latter, 50.0% also faced difficulties in this aspect. With respect to work-life balance barriers, 40.9% of women and 13.8% of men reported them. Conclusion: The perception of disparities among cardiologists reveals a trend where men face barriers in economic development, while women struggle to find a work-life balance. This highlights the urgency of implementing proactive strategies to promote gender equality in cardiology and ensure an inclusive and equitable professional environment.

Blacking Out the Archive in Jasminne Mendez's City without Altar

Abstract: This essay introduces readers to a recent choreopoem, or a play that is choreographed as a poem, by Afro-Latiné author, poet, playwright, performer, and educator Jasminne Mendez, titled City without Altar . The choreopoem centers the transhistorical experience of a massacre of Afro-Dominican and Haitian populations that occurred on the northern Dominican border between Haiti and the Dominican Republic in the town of Dajabón. I name it as transhistorical because of Mendez's intuitive and intersubjective mode of writing that connects her experiences with disabilities, which resemble those of el corte, with the afterlives of the victims themselves. I argue that Mendez provides a genealogical and aesthetic study of el corte that centers a Afro-Dominican femme interior life that is structured by the particularity of its afterlife.

P183 PERIPARTUM CARDIOMYOPATHY: MONOCENTRIC DESCRIPTION AT THE NORTHERN REGIONAL MATERNITY HOSPITAL OF THE DOMINICAN REPUBLIC

Background: Peripartum cardiomyopathy (PPCM) is a pathology in which the woman's heart dilates and displays signs and symptoms of heart failure. It is a rare pathology, with a high mortality rate, and predominance in black patients. Its diagnosis and management are not standardized, nor adapted to low income countries. This leads to barriers in identifying and treating the disease in higher-risk countries such as Haiti, making it a relevant issue in the Dominican Republic due to high immigration of haitians to the country. Therefore we aimed to evaluate the association of risk factors and the pharmacological regimen of patients in a public healthcare center in the Dominican Republic. Methods: An observational, retrospective, cross-sectional study was carried out with convenience sampling. This included patients who had been admitted to the Presidente Estrella Ureña Regional Hospital with suspected PPCM during the last 3 years. Variables studied include: sociodemographic factors, toxic habits, pathological and gynecological-obstetric history, cardiovascular, pulmonary and general signs and symptoms. Results: A sample of 19 patients with a median age of 27 years was obtained, 73.4% of them were black. All of the patients who had illness onset in the peripartum period (first 28 days after labor) presented adverse events, infectious comorbidities and “other comorbidities” while 75% of them presented cardiac and pulmonary comorbidities. Regarding treatment, only 77.8% of patients with antepartum onset received treatment in this period. Additionally, 66.7% of patients with antepartum onset developed adverse events that required oxygen-supplementation, versus only 33% of those without adverse events. Conclusions: It is relevant to design tools for calculating the risk of developing PPCM and standardize its disparate diagnosis and treatment, particularly aimed at countries with limited resources. This aims to improve the prognosis in patients with risk factors such as: black race, age over 30 years and living in low/middle-resource countries.

Every intrusion has its time: New zircon U-Pb ages from the Greater Antilles Arc in the Cordillera Central, Dominican Republic

The Cordillera Central on the island of Hispaniola comprises a section through the crust of the Late Cretaceous phase of the Greater Antilles Arc. The gabbroic-tonalitic batholiths of the Cordillera Central are widely considered to represent the temporal main axis of this island arc. Although they have been studied extensively, the timing of batholith emplacement is not well constrained. We present new LA-ICP-MS U-Pb zircon ages and whole-rock geochemical data from diorites, tonalites, and granites of the El Río, El Bao, Jumunuco, and Loma de Cabrera batholiths, and from tonalite boulders deposited in the Eocene-Oligocene Velázquitos Formation. The sample ages range from 97 to 80 Ma with small differences between the intrusive bodies. Samples from the El Río, Jumunuco, and Loma de Cabrera batholiths cover most of the above age range, while the rocks of the El Bao pluton yield a well-defined maximum around 87 Ma. In the El Río batholith, U-Pb ages are in good agreement with the exposed contact relationships. Based on their composition and existing geochronological data, we divide the intrusive history of the Cordillera Central into four stages reflecting different magma compositions: ultramafic to dioritic magmatism lasted from 105 to 87 Ma, tonalite units formed between 96 and 84 Ma, felsic tonalites and granites intruded from 87 to 80 Ma overlapping with a younger phase of dioritic magmatism between 84 and 78 Ma.The geochemical signatures of the felsic tonalites of the Jumunuco batholith and the granites of the El Río batholith are similar to the rhyolitic and dacitic island-arc volcanics from the Restauración Formation of the Tireo Group, thus confirming the relationship between the volcanic and plutonic units of the Greater Antilles Arc. Based on petrographical, geochemical, and geochronological data of the tonalite samples from the Velázquitos Formation, we interpret these boulders as being eroded from the Jumunuco batholith or the related Buena Vista pluton.

Traidores a la patria: Reconfiguring the nation through (un)patriotic discourse in the Dominican Republic

AbstractIn June 2020 anti‐racist activists in the Dominican Republic holding a vigil for George Floyd, who was brutally murdered by the police in the United States, were assaulted by right‐wing ultranationalists and detained by the national police. An event that was meant to express transnational solidarity was seen as a threat by ultranationalists who over the past decades supported anti‐Haitian and anti‐Black state policies that have contested the rights of Dominicans of Haitian descent to Dominican nationality and citizenship. This article explores how through the Dominican state's refashioning of the legal and juridical apparatus, as well as the support of self‐proclaimed Dominican nationalists, interpretations of Dominican national belonging are being contested and reimagined through the use of words such as traidor (traitor) and haitiano (Haitian). These terms code proper nationalism and Dominicanness as mixed‐race, Hispanic, and anti‐Haitian, as well as pro‐Dominican sovereignty, therefore against international human rights organizations.

Hypertension Prevalence among Hispanics/Latinos of Dominican Background: A Transnational Comparison of HCHS/SOL and ENPREFAR-HAS-17.

Hispanics/Latinos of Dominican background living in United States (US) have the highest hypertension prevalence compared with other Hispanic/Latino persons. To understand cardiovascular health among Dominicans, we evaluated hypertension prevalence and risk factors among Dominicans from the US and Dominican Republic (DR) using data from Hispanic Community Health Study/ Study of Latinos [HCHS/SOL] and the Prevalencia de Hipertension Arterial y Factores de Riesgo Cardiovasculares en la República Dominicana al 2017 (ENPREFAR-HAS 17) study. Hypertension was defined as blood pressure ≥140/90 mmHg, self-reported hypertension, or antihypertensive use. Exposures included sociodemographic/socioeconomic, clinical, and lifestyle/behavioral characteristics. Weighted generalized linear models were used to estimate associations between study characteristics and hypertension prevalence (PR = prevalence ratio), age-and-sex adjusted. HCHS/SOL (n = 1,473, US Dominicans; mean age 41 years, 60.4% female) was analyzed with survey procedures, while ENPREFAR-HAS 17 (n = 2,015 DR Dominicans; mean age 40 years, 50.3% female) was analyzed with statistical analyses for simple random sampling. Hypertension prevalence was 30.5% and 26.9% for DR and US Dominicans, respectively. Hypertension control was low in both cohorts (36.0% DR, 35.0% US). Alcohol use among DR Dominicans was inversely associated with hypertension prevalence (PRDR = 0.8) with no association among US Dominicans. In both settings, diabetes (PRDR = 1.4; PRUS = 1.4) and obesity (PRDR = 1.8; PRUS = 2.0) were associated with greater hypertension prevalence in Hispanics/Latinos of Dominican background. Physical activity was lower among US Dominicans (PR = 0.80) but higher among DR Dominicans (PR = 1.16); all p < 0.05. Variations in social, lifestyle/behavioral, and clinical characteristics associated with hypertension among Dominicans in the US and DR were identified, suggesting that social context and cultural factors matter among immigrant populations.

Safety and Immunogenicity of Trivalent Oral Polio Vaccine in Vaccinated Children and Vaccine-Naïve Infants: A Phase 4 Study.

In the context of polio eradication, novel oral polio vaccines for type 2 (nOPV2) were developed, and types 1 and 3 polioviruses are being developed. We aimed to generate trivalent oral poliovirus vaccine (tOPV) safety and immunogenicity data as a reference for comparing with novel OPV formulations. This was a single-center, open-label, phase 4 study in March 2016 in the Dominican Republic with healthy children previously vaccinated with ≥3 doses of tOPV receiving one dose of tOPV and vaccine-naïve infants receiving 3 doses of tOPV. Safety and immunogenicity were assessed. No serious adverse reactions or important medical reactions were reported. Seroconversion (SC) rates at Day 28 in children were 32.7%, 36.7%, and 46.9% for types 1, 2, and 3, respectively, and seroprotection (SP) rates 28 days after one dose increased from 89.8% at baseline to 93.9%, 98.0% to 100%, and 83.7% to 98.0% for types 1, 2, and 3, respectively. In infants, SC rates were 88.5%, 98.1%, and 96.2% for types 1, 2, and 3, respectively. SP rates at Day 84 were 93.3%, 100%, and 96.2% for types 1, 2, and 3, respectively. This information can be used as a reference to compare with novel monovalent or trivalent OPVs under development.

Cultural Landscapes in the Central American Region: Analysis of the Legal Framework for Protection and Management

The eight member countries of the Central American Integration System (SICA)—Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and the Dominican Republic—are signatories to the Convention for the Protection of World Heritage and the Convention on Biological Diversity. Both binding international instruments use the terms ‘cultural landscape’ and ‘protected landscape’, respectively. For this reason, the environmental/natural and cultural legislation of the SICA region has been analyzed to identify the legal frameworks that allow for the declaration of the categories mentioned above for the protection of landscapes. In five of the eight SICA member states, 38 ‘protected landscapes’ were found to exist under environmental law. No designation has been reported for cultural legislation in this region. In addition, the designations and management plans for ‘protected landscapes’ were reviewed, and it was noted that most of them were similar in denomination, but their protection objectives were not aligned with the binding instruments from which they were derived. Thus, we conclude that, given the particular natural and cultural wealth of the SICA region, it is necessary to identify and map landscapes and establish common guidelines for managing them to foster harmony between nature and mankind and according to the international conventions’ objectives.

Monetary Policy Reaction to COVID-19 and Their Economic Impact in Central America and the Dominican Republic

Monetary Policy Reaction to COVID-19 and Their Economic Impact in Central America and the Dominican Republic

Probabilistic seismic hazard analysis for the Dominican Republic

The Dominican Republic experiences moderate to high seismic hazard mostly caused by oblique convergence at the Caribbean/North American plate boundary that manifests as subduction zones, less-pronounced subduction-like trenches with thrust faulting, long strike-slip faults parallel to the plate boundary, and onshore deformation. Historical earthquakes have damaged the Dominican Republic’s large cities and those in neighboring Haiti, once requiring relocation. Given this, the Dominican Republic joined the “Training and Communication for Earthquake Risk Assessment” (TREQ) project funded by the United States Agency for International Development, which aimed to increase earthquake risk assessment capacity in Latin American cities. The TREQ project was the basis for developing an openly available probabilistic seismic hazard model for the Dominican Republic. The input model was developed from two main datasets: a homogenized earthquake catalog and an active faults database that combines results of recent local projects with a global database. The seismic source characterization used these to constrain source geometries and occurrence rates for active shallow crustal earthquakes, subduction interfaces and subduction-like thrusts, and intraslab earthquakes. Shallow crustal earthquakes, including those on subduction-like thrusts, are modeled by smoothed seismicity and fault sources, the latter using pre-defined geometries that permit multi-fault ruptures. Seismicity on the Puerto Rico Trench subduction interface is modeled as a fault source, while intraslab sources use pre-defined gridded ruptures inside the intraslab volume. The source characterization applies epistemic uncertainties to modeling assumptions affecting occurrence rates and maximum magnitudes. The ground motion characterization used residual analyses from past regional projects as a basis, updating some components with more recent ground motion models. Computed hazard results reinforce those from recent studies in terms of geographical hazard patterns and levels. For 475-year return periods, peak ground acceleration (PGA) in Santiago de los Caballeros reaches 0.50 g, controlled by the Septentrional Fault, while all tectonic region types contribute to the PGA 0.31 g computed for Santo Domingo.

Cap a una geografia líquida: Anna Murià i els camins i fluxos de la commemoració

This article sets out to address the presence/absence of female writers in processes of commemoration of literary figures in contemporary Catalan culture, focusing on the case of Anna Murià (1904–2002). Recently included among the ten “classic” writers presented as part of the volume Women Writers in Catalan (Huerga, 2017), the process of her recovery for a possible feminine – let alone feminist – canon has been complicated by the fact that she dedicated the majority of her life, after 1939, to consolidating the “voice” of her husband, the poet Agustí Bartra, in exile in the Dominican Republic, Cuba, Mexico and the US, and after the couple’s return to Catalonia in 1970. Considering different moments of Murià’s commemorative labour and reception – from the moment of return; through the death of Bartra in 1982; to posthumous reframings after her own death in 2002 – the article explores the debates and ambivalence surrounding her significance, as a figure which, depending on the perspective of the reader, can be employed to represent: Republican memory; the continuity of exile; the experience of being a woman; feminism and feminine creativity; and/or the subordination of her own subjectivity to that of her husband and life partner, Bartra. Rather than attempting to resolve this ambivalence, this article will show how a more attentive, genealogical reading of her work enables us to contrast the inescapably patriarchal politics of monumentalizing associated with national memory cultures with the more fluid and relational ethics that characterise her own commemorative labour and writing of the self: as a call to imagine and begin to formulate alternative practices of memorialization.

Screening evaluation of the quality of commercially available cigars, cigarillos, and bidis based on emission levels of selected terpenes and terpenoids

The aim of the research was to verify the use of the solvent-free, non-destructive and easy to operate analytical method to study and compare the emissions of 16 representatives of terpenes and terpenoids from commercially available cigars, cigarillos and bidis − a potential screening analysis for the quality of combustible tobacco products. To assess the amount of organic compounds emitted to the gaseous phase from investigated tobacco samples, the stationary emission chambers system (at the sample conditioning stage) and gas chromatography with flame ionization detector (at the final analyte determination stage) were used. Studied samples represented five origins: the Dominican Republic, Nicaragua, Mexico, Cuba, and India and two manufacture approaches: machine-made and handmade. The assessed values of total volatile organic compounds (TVOCs) was from 0.58 to 28 µg·g−1 (at 60 °C) and from 26 to 430 µg·g−1 (at 120 °C). For Dominican products, Camphene and α-Cedrene were characterized by the highest emission level (233 ± 34 ng·g−1 and (3.7 ± 1.4) × 102 ng·g−1, respectively). In a case of Mexican and Cuban products it was noticed that the emission level of determined terpenes and terpenoids is higher in the case of hand-rolled tobacco products than mechanically manufactured ones. In a case of Nicaraguan hand-rolled products, Camphene, L-(−)-Fenchone, and α-Cedrene were characterized by the highest emission rate at 120 °C (213 ± 81 ng·g−1, 191 ± 45 ng·g−1 and 213 ± 84 ng·g−1, respectively). The highest emission level for Indian products in 120 °C was observed for α-Cedrene and Geranyl Acetate – respectively 181.6 ± 4.4 ng·g−1 and 101 ± 13 ng·g−1. The results of this study may indicate that sometimes cheaper products such as cigarillo have an emission profile that classifies them between expensive products such as “large cigars.”

Belonging between precarity and hope: immigration, tourism, and violence in the Dominican Republic

Belonging between precarity and hope: immigration, tourism, and violence in the Dominican Republic

An extensive review of mutualistic and similar ecological associations involving tarantulas (Araneae: Theraphosidae), with a new hypothesis on the evolution of their hirsuteness

ABSTRACT Mutualistic and similar ecological associations between tarantulas (Mygalomorphae: Theraphosidae) and other animals are reviewed. Such associations are found to occur in at least nine theraphosid subfamilies. We present 63 new cases of theraphosid–anuran associations from 10 countries, documenting these interactions for the first time in Brazil, Chile, the Dominican Republic, and the Philippines. These findings are the first documentation of such associations for 13 theraphosid and 20 anuran taxa. Additionally, we report, for the first time, associations potentially of mutualistic nature between tarantulas and snakes, whip spiders, and harvestmen. Furthermore, we provide new reports of associations with ants and termites. While some of these interactions appear to be merely tolerated cohabitations, those involving anurans and ants seem to be more prevalent and complex, clearly offering benefits for both organisms. Additionally, based on multiple observations and field experiments, we propose a new hypothesis regarding the evolution of hirsuteness in theraphosids as a defensive strategy against predatory ants. This hypothesis supports previous findings that suggest a similar function for urticating setae incorporated into egg sacs and moulting mats. We further document a unique escape strategy against ants in New World arboreal theraphosids. Finally, the possibility of a chemical defence mechanism through specialised epidermal glands in theraphosids is briefly discussed.

Perceived and Pursued Opportunities from Mass Deportation Threats: The Case of Haitian Migrant-Serving Nonprofit Organizations in the Dominican Republic

Abstract The threat of deportation is a common experience shared by migrants around the world. Migrant-serving nonprofit organizations must also contend with these threats. While there is considerable research on how nonprofits serve migrants, there is a lack of research that explores what mass deportation threats may mean for nonprofits actors and their work. In order to address this gap, this study explores the case of the Dominican Republic where there was widespread fear that mass removals would occur after the closing of the National Regularization Plan for Foreigners on June 17, 2015. Using semi-structured interviews with 20 nonprofit actors from Haitian-migrant serving organizations, a qualitative content analysis reveals three main themes that capture how nonprofits perceived and pursued opportunities from the threat of deportation. They include the opportunity to grow, the opportunity to advocate, and the opportunity to learn and educate. This research is important for shedding light on the organizational resilience of migrant-serving nonprofits in the Dominican Republic and offers insight into how policies might be developed to support nonprofits as they address migration policies in their work.

Pharmaceutical Market Access in Latin America: Analyzing Approval Requirements in Three Key Nations: Ecuador, Dominican Republic and Nicaragua

: This article presents a comprehensive and comparative analysis of the regulatory frameworks governing the approval of pharmaceuticals in the Dominican Republic, Ecuador, and Nicaragua. It delves into the intricate scientific terminology and complex procedures inher-ent in these regulatory systems, shedding light on the demanding requirements that pharmaceu-tical companies must fulfil to secure market access in these countries. Employing a comparative approach, the article explores both the analogy and differences in the approval processes, focus-ing on factors such as safety standards, efficacy assessments, clinical trial prerequisites, post-marketing surveillance, and overall transparency. The findings contribute to a deeper under-standing of the scientific accuracy and ongoing efforts towards regulatory harmonisation within the pharmaceutical industry across these countries. Furthermore, this study aims to define the regulatory requirements for drug approval in the LATAM region, explicitly emphasising the Dominican Republic, Ecuador, and Nicaragua. It provides insights into the current pharmaceuti-cal market landscape in Latin America, compares the regulatory requirements for drug approval in these three countries, and offers guidance on preparing dossiers for obtaining authorisation of pharmaceutical drug products. By examining the similarities and differences in regulatory stand-ards, this article facilitates a comprehensive understanding of the stringency ratios between these countries and assists companies in navigating the specific regulatory landscapes to achieve suc-cessful drug approvals

Dominican Republic

Dominican Republic

Venciendo la Desesperación Cristalizada

Racism and xenophobic discrimination in the Dominican Republic, especially state policies against black people of Haitian origin, oppress a community with a long history of exploitation and resistance in the country every day. This oppression affects, in multiple ways, the life and health of those who engage in social activism and the defense of human rights, and who do so under constant threat of repression and even death, in a context where far right organizations frequently work in coordination with authorities to block protest and public action. Although racism is institutionalized and structural in nature, state authorities advance negationist discourses, minimizing or denying grave historical facts such as the massacre of 1937, the racist campaign against the late politician José Francisco Peña Gómez, the law 168-13 that retroactively removed the nationality of more than four generations of person of Haitian origin. The combination of a struggle that is increasingly better endowed with theoretical tools and politics to change this reality of racist oppression and the realization of studies on the wear and tear that racism imposes on our health, enable us to deepen perspectives of liberation for new generations of activists.

Profundizando en la bioecología de Culex interrogator Dyar y Knab, 1906 (Diptera: Culicidae) en Camagüey, Cuba

Culex interrogator is a culicid species that has recently been reported in the insular Caribbean, first in Cuba, specifically in the province of Santiago de Cuba, and shortly afterward in the Dominican Republic. This study’s objective is to report for the first time the presence of Cx. interrogator in the Cuban province of Camagüey and investigate its larval breeding sites in the urban environment. In 2022, visual inspections were conducted in all dwellings and facilities in the municipality of Camagüey, including intra- and peridomiciliary areas in the urban and suburban regions. In each positive mosquito reservoir, as many larvae and pupae as possible were collected. A total of 30 samples positive for Cx. interrogator (n = 155 larvae) were collected from 13 types of reservoirs. Ditches were the most frequent reservoir with the species present (n = 8; 26.66%), followed by ground-level tanks and sewage pits (n = 4; 13.33% each). All positive reservoirs were located in outdoor areas of dwellings. The discovery of this mosquito species in Camagüey, with many unknown aspects of its role as a vector, highlights the need for close monitoring and in-depth study.

Effects of cultural stressors and family etiologic factors on behavioral and mental health among Mexican and other Latino/a immigrant parents in the United States

As the Latino/a population in the United States continues to grow, disparities among subgroups within this population are becoming more evident. Understanding how cultural stressors and family dynamics relate to behavioral and mental health outcomes among Latino/a immigrants offers valuable insights for addressing inequities among specific Latino/a subgroups. As a result, we conducted a moderated-mediation analysis, using a multi-group path analysis approach, to examine the extent to which cultural stressors and family etiologic factors relate to hazardous alcohol use and mental health symptoms among Mexican and other Latino/a immigrant (i.e., Argentina, Chile, Colombia, Peru, Uruguay, Venezuela, Cuba, Dominican Republic, Costa Rica, Guatemala, Honduras, Nicaragua, Panama, and El Salvador) parents in the United States. Additionally, we explored the extent to which cultural stressors would indirectly relate to hazardous alcohol use and mental health symptoms through elevated family risk factors and compromised family functioning among both subgroups. The sample consisted of 827 Latino/a immigrant parents with children aged 8 to 16 years, including 287 (35 %) Mexican (M=38.9 years, 61 % female) and 540 (65 %) other Latino/a (M=40.8 years, 72 % female). Variables assessed in this study, and self-reported by participants, included cultural stress, family conflict, poor family management, positive attitudes toward drug use, family functioning, hazardous alcohol use, and symptoms of anxiety and depression. We conducted a series of multiple linear regressions, as well as a multigroup path analysis adjusting for covariates. Scores on all study variables (except family functioning, which evidenced the opposite pattern) were significantly greater in Mexicans than in other Latino/a individuals. We found that hazardous alcohol use was more closely related to family and cultural level predictors among Mexicans, but that links of family and cultural level predictors with mental health indicators were similar between the two subgroups. Grouping Mexicans into a homogenous ethnic group along with other Latino/a subgroups might undermine our understanding of the associations of cultural stress and family-level etiologic factors vis-à-vis the incidence and prevention of hazardous alcohol use and mental health among different subgroups of Latino/a immigrant families, especially those of Mexican origin. Our findings highlight the critical need for tailored interventions aimed at Latino/a immigrant subgroups to ensure equitable substance use and mental health outcomes in the United States.