Richard Scribner

Neighborhood Physical Conditions and Health

OBJECTIVES We explored the relationship between boarded-up housing and rates of gonorrhea and premature mortality. METHODS In this ecological study of 107 US cities, we developed several models predicting rates of gonorrhea and premature death before age 65 from all causes and from specific causes. We controlled for race, poverty, education, population change, and health insurance coverage. RESULTS Boarded-up housing remained a predictor of gonorrhea rates, all-cause premature mortality, and premature mortality due to malignant neoplasms, diabetes, homicide, and suicide after control for sociodemographic factors. CONCLUSIONS Boarded-up housing may be related to mortality risk because of its potential adverse impact on social relationships and opportunities to engage in healthful behaviors. Neighborhood physical conditions deserve further consideration as a potential global factor influencing health and well-being.

The risk of assaultive violence and alcohol availability in Los Angeles County.

OBJECTIVES Although there is considerable evidence that alcohol consumption facilitates assaultive violence, the extent to which alcohol outlets in a community influence assaultive violence remains controversial. METHODS To assess the geographic association between city-specific rates of assaultive violence and alcohol-outlet density, an ecologic analysis of the 74 larger cities in Los Angeles County was conducted for the 1990 reporting year. RESULTS Sociodemographic factors alone accounted for 70% (R2 = .70) of the variance in the rate of assaultive violence in a multiple regression model. Adding the variable for alcohol-outlet density to the model yielded a significant positive slope. The magnitude of this relation indicates that in a typical Los Angeles County city (50,000 residents, 100 outlets, 570 offenses per year), one outlet was associated with 3.4 additional assaultive violence offenses in 1990. CONCLUSIONS These findings indicate that higher levels of alcohol-outlet density are geographically associated with higher rates of assaultive violence. This association is independent of measured confounders, including city-level measures of unemployment, ethnic/racial makeup, income, age structure, city size, household size, and female-headed households.

Implementation of condom social marketing in Louisiana, 1993 to 1996.

OBJECTIVES This article describes the implementation and impact of the first statewide condom social marketing intervention in the United States. METHODS A statewide social marketing program made condoms freely available in 93 public health clinics, 39 community mental health centers, 29 substance abuse treatment sites, and more than 1000 businesses in neighborhoods with high rates of sexually transmitted diseases (STDs) and HIV. Surveys about condom use were conducted annually. RESULTS Between 1994 and 1996, more than 33 million condoms were distributed without significant opposition. Over time, self-reported condom use at the last sexual encounter increased among African American women (from 28% in 1994 to 36% in 1996), particularly African American women with 2 or more sex partners (from 30% to 48%). Condom use at the last sexual encounter increased among African American men (from 40% in 1994 to an average of 54% in 1996). The number of reported sex partners did not increase. CONCLUSIONS Condom social marketing can be successfully implemented in the United States. The widespread availability of free condoms is associated with increased condom use, particularly among persons at high risk for STDs and HIV.

A multisite randomized trial of social norms marketing campaigns to reduce college student drinking: A replication failure.

ABSTRACT A 14-site randomized trial tested the effectiveness of social norms marketing (SNM) campaigns, which present accurate student survey data in order to correct misperceptions of subjective drinking norms and thereby drive down alcohol use. Cross-sectional student surveys were conducted by mail at baseline and at posttest 3 years later. Hierarchical linear modeling was applied to examine multiple drinking outcomes, taking into account the nonindependence of students grouped in the same college. Controlling for other predictors, having a SNM campaign was not significantly associated with lower perceptions of student drinking levels or lower self-reported alcohol consumption. This study failed to replicate a previous multisite randomized trial of SNM campaigns, which showed that students attending institutions with a SNM campaign had a lower relative risk of alcohol consumption than students attending control group institutions (W. DeJong et al. J Stud Alcohol. 2006;67:868–879). Additional research is needed to explore whether SNM campaigns are less effective in campus communities with relatively high alcohol retail outlet density.

A geographic relation between alcohol availability and gonorrhea rates

Background and Objectives: The availability of alcohol measured as alcohol outlet density is associated with numerous alcohol‐related outcomes in small area analysis. A number of studies suggest that high‐risk sexual behavior should also be considered an alcohol‐related outcome. Goal of this Study: To assess the geographic relationship between alcohol availability and high‐risk sexual behavior at the neighborhood level. Study Design: Ecological analysis of the geographic relation between off‐premise, on‐premise, and total alcohol outlet density and reported gonorrhea rates among 155 urban residential census tracts in New Orleans during 1995. Results: All alcohol outlet density variables were positively related to gonorrhea rates. Off‐premise outlets per square mile was most strongly related to gonorrhea rates (β ± SE) (β = 0.582 ± 0.073), accounting for 29% of the variance in gonorrhea rates. Interpreted as an elasticity, a 10% increase in off‐sale alcohol outlet density accounts for a 5.8% increase in gonorrhea rates. Including the covariates percent black and percent unemployed to the model reduced but did not remove the effect of off‐sale outlet density (β = 0.192 ± 0.047). Conclusions: These results indicate there is a geographic relationship between alcohol outlet density and gonorrhea rates at the census tract level. Although these results cannot be interpreted causally, they do justify a public health intervention as a next step in defining the relation between alcohol availability and high‐risk sexual behavior.

Cost as a barrier to condom use: the evidence for condom subsidies in the United States.

OBJECTIVES This study sought to determine the impact of price on condom use. METHODS A program based on distribution of condoms at no charge was replaced with one providing low-cost condoms (25 cents). Pretest and posttest surveys asked about condom use among persons reporting 2 or more sex partners. RESULTS At pretest, 57% of respondents had obtained free condoms, and 77% had used a condom during their most recent sexual encounter. When the price was raised to 25 cents, the respective percentages decreased to 30% and 64%. CONCLUSIONS Cost is a barrier to condom use. Free condoms should be distributed to encourage their use by persons at risk for HIV and other sexually transmitted diseases.

Alcohol availability and neighborhood characteristics in Los Angeles, California and southern Louisiana.

The objective of this study was to examine the associations between alcohol availability types and community characteristics in randomly selected census tracts in Southern California and Southeastern Louisiana. Outlet shelf space and price by beverage type was collected from all off-sale alcohol outlets in 189 census tracts by trained research personnel. Three aspects of alcohol availability at the census tract level were considered—outlets per roadway mile, shelf space, and least price by beverage type. Using multivariate analyses, we examined the associations between census tract socioeconomic and demographic characteristics and alcohol availability types. Fifteen measures of alcohol availability were calculated—total shelf space and shelf space by beverage types (beer, malt liquor, and distilled spirits); outlets per roadway mile, per tract, and per capita; and least price by beverage type (including wine). In multivariate analyses controlling for state, male unemployment rate was inversely associated with total shelf space (p = 0.03) and distilled spirit shelf space (p = 0.05). Malt liquor shelf space was inversely associated with percent White (p = 0.02). Outlets per roadway mile was positively associated with household poverty (p < 0.0001), whereas percent African American was inversely associated with outlets per roadway mile (p = 0.03). Beverage-specific least prices were not associated with any socioeconomic or demographic community characteristics. Alcohol availability types, but not least price, were associated with some community characteristics. More research exploring how alcohol availability types vary by community and their relationship to alcohol-related harms should be conducted.

The Neighborhood Alcohol Environment and Alcohol-Related Morbidity

AIMS The aims of this study were (1) to examine the association between neighborhood alcohol outlet density and individual self-reported alcohol-related health outcomes in the last year-sexually transmitted infections (STI), motor vehicle accidents, injury, liver problems, hypertension and experienced violence; (2) to determine whether the relationship between morbidity and alcohol outlet density is mediated by individual alcohol consumption; and (3) to explore the role of alcohol outlet density in explaining any observed racial and ethnic differences in morbidity. METHOD Hierarchical models from a random sample of Los Angeles, CA, and Louisiana residents (N = 2881) from 217 census tracts were utilized. The clustering of health and social outcomes according to neighborhood varied by health problem examined. RESULTS There was substantial clustering of STI (intraclass correlation coefficient, ICC = 12.8%) and experienced violence (ICC = 13.0%); moderate clustering of liver problems (ICC = 3.5%) and hypertension (ICC = 3.9%); and low clustering of motor vehicle accident (ICC = 1.2%) and injury (ICC = 1.4%). Alcohol outlet density was significantly and positively associated with STI (crude OR = 1.80, 95% CI = 1.10-3.00), liver problems (crude OR = 1.33, 95% CI = 1.02-1.75) and experienced violence (crude OR = 1.31, 95% CI = 1.13-1.51) although not with other morbidity outcomes. Mediation analyses of morbidity outcomes revealed partial mediation of individual alcohol consumption in the relationship between alcohol density and STI and violence, and full mediation for liver problems. CONCLUSIONS Findings support the concept that off-premise alcohol outlets in the neighborhood environment may impact health and social outcomes, either directly or indirectly, through individual alcohol consumption and these associations may be heterogeneous with respect to race and ethnicity.

Impact of small group size on neighbourhood influences in multilevel models

Background Given the growing availability of multilevel data from national surveys, researchers interested in contextual effects may find themselves with a small number of individuals per group. Although there is a growing body of literature on sample size in multilevel modelling, few have explored the impact of group sizes of less than five. Methods In a simulated analysis of real data, the impact of a group size of less than five was examined on both a continuous and dichotomous outcome in a simple two-level multilevel model. Models with group sizes one to five were compared with models with complete data. Four different linear and logistic models were examined: empty models; models with a group-level covariate; models with an individual-level covariate and models with an aggregated group-level covariate. The study evaluated further whether the impact of small group size differed depending on the total number of groups. Results When the number of groups was large (N=459), neither fixed nor random components were affected by small group size, even when 90% of tracts had only one individual per tract and even when an aggregated group-level covariate was examined. As the number of groups decreased, the SE estimates of both fixed and random effects were inflated. Furthermore, group-level variance estimates were more affected than were fixed components. Conclusions Datasets in which there is a small to moderate number of groups, with the majority of very small group size (n<5), size may fail to find or even consider a group-level effect when one may exist and also may be underpowered to detect fixed effects.

Social capital and the neighborhood alcohol environment

We examine whether neighborhood alcohol outlet density is associated with reduced social capital and whether this relationship is mediated by perceived neighborhood safety. Hierarchical models from a random sample of Los Angeles, CA, and Louisiana residents (N=2,881) from 217 census tracts were utilized. Substantial proportions of the variance in collective efficacy (intraclass correlation coefficient, ICC=16.3%) and organizational participation (ICC=13.8%, median odds ratio=1.99) were attributable to differences between neighborhoods-suggesting that these factors may be influenced by neighborhood-level characteristics. Neighborhood alcohol outlet density was strongly associated with reduced indicators of social capital, and the relationship between collective efficacy and outlet density appears to be mediated by perceived neighborhood safety. Findings support the concept that off-premise alcohol outlets in the neighborhood environment may hinder the development of social capital, possibly through decreased positive social network expansion.