Shelley D. Golden

Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions

Social ecological models that describe the interactive characteristics of individuals and environments that underlie health outcomes have long been recommended to guide public health practice. The extent to which such recommendations have been applied in health promotion interventions, however, is unclear. The authors developed a coding system to identify the ecological levels that health promotion programs target and then applied this system to 157 intervention articles from the past 20 years of Health Education & Behavior. Overall, articles were more likely to describe interventions focused on individual and interpersonal characteristics, rather than institutional, community, or policy factors. Interventions that focused on certain topics (nutrition and physical activity) or occurred in particular settings (schools) more successfully adopted a social ecological approach. Health education theory, research, and training may need to be enhanced to better foster successful efforts to modify social and political environments to improve health.

Troubled Times, Troubled Relationships: How Economic Resources, Gender Beliefs, and Neighborhood Disadvantage Influence Intimate Partner Violence

We evaluate race/ethnicity and nativity-based disparities in three different types of intimate partner violence (IPV) and examine how economic hardship, maternal economic dependency, maternal gender beliefs, and neighborhood disadvantage influence these disparities. Using nationally representative data from urban mothers of young children who are living with their intimate partners (N = 1,886), we estimate a series of unadjusted and adjusted logit models on mothers’ reports of physical assault, emotional abuse, and coercion. When their children were age 3, more than one in five mothers were living with a partner who abused them. The prevalence of any IPV was highest among Hispanic (26%) and foreign-born (35%) mothers. Economic hardship, economic dependency on a romantic partner, and traditional gender beliefs each increased women’s risk for exposure to one or more types of IPV, whereas neighborhood conditions were not significantly related to IPV in adjusted models. These factors also explained most of the racial/ethnic and nativity disparities in IPV. Policies and programs that reduce economic hardship among women with young children, promote women’s economic independence, and foster gender equity in romantic partnerships can potentially reduce multiple forms of IPV.

Structural Approaches to Health Promotion What Do We Need to Know About Policy and Environmental Change

Although the public health literature has increasingly called on practitioners to implement changes to social, environmental, and political structures as a means of improving population health, recent research suggests that articles evaluating organization, community, or policy changes are more limited than those focused on programs with individuals or their social networks. Even when these approaches appear promising, we do not fully understand whether they will benefit all population groups or can be successful in the absence of accompanying individually oriented programs. The role of this broad category of approaches, including both policy and environmental changes, in decreasing health disparities is also unclear, often benefiting some communities more than others. Finally, the political nature of policy and environmental change, including the impact on personal autonomy, raises questions about the appropriate role for public health professionals in advancing specific policies and practices that alter the conditions in which people live. This article addresses these issues and ends with a series of questions about the effectiveness and ethical implementation of what we have termed “structural initiatives.”

Upending the Social Ecological Model to Guide Health Promotion Efforts Toward Policy and Environmental Change

Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere.

Beyond excise taxes: a systematic review of literature on non-tax policy approaches to raising tobacco product prices

Objective Raising the price of tobacco products is considered one of the most effective ways to reduce tobacco use. In addition to excise taxes, governments are exploring other policies to raise tobacco prices and minimise price dispersion, both within and across price tiers. We conducted a systematic review to determine how these policies are described, recommended and evaluated in the literature. Data sources We systematically searched six databases and the California Tobacco Control library for English language studies or reports, indexed on or before 18 December 2013, that included a tobacco keyword (eg, cigarette), policy keyword (eg, legislation) and a price keyword (eg, promotion). We identified 3067 abstracts. Study selection Two coders independently reviewed all abstracts and identified 56 studies or reports that explicitly described a public policy likely to impact the retail price of tobacco products through non-tax means. Data extraction Two coders independently identified tobacco products targeted by policies described, recommendations for implementing policies and empirical assessments of policy impacts. Data synthesis The most prevalent non-tax price policies were price promotion restrictions and minimum price laws. Few studies measured the impact of non-tax policies on average prices, price dispersion or disparities in tobacco consumption, but the literature includes suggestions for crafting policies and preparing for legal challenges or tobacco industry opposition. Conclusions Price-focused evaluations of well-implemented non-tax price policies are needed to determine whether they can deliver on their promise to raise prices, reduce price dispersion and serve as an important complement to excise taxes.

Taxing sin and saving lives: Can alcohol taxation reduce female homicides?

With costs exceeding

Disparities in tobacco marketing and product availability at the point of sale: Results of a national study

5.8 billion per year, violence against women has significant ramifications for victims, their families, the health care systems that treat them, and the employers who depend on their labor. Prior research has found that alcohol abuse contributes to violence against both men and women, and that stringent alcohol control policies can reduce alcohol consumption and in turn some forms of violence. In this paper, we estimate the direct relationship between an important alcohol control measure, excise taxes, and the most extreme form of violence, homicide. We use female homicide rates as our measure of severe violence, as this measure is consistently and accurately reported across multiple years. Our results provide evidence that increased alcohol taxes reduce alcohol consumption and that reductions in alcohol consumption can reduce femicide. Unfortunately, a direct test of the relationship does not have the power to determine whether alcohol taxes effectively reduce female homicide rates. We conclude that while alcohol taxes have been shown to effectively reduce other forms of violence against women, policy makers may need alternative policy levers to reduce the most severe form of violence against women.

Frequency and content of conversations about pictorial warnings on cigarette packs

OBJECTIVE Neighborhood socioeconomic and racial/ethnic disparities exist in the amount and type of tobacco marketing at retail, but most studies are limited to a single city or state, and few have examined flavored little cigars. Our purpose is to describe tobacco product availability, marketing, and promotions in a national sample of retail stores and to examine associations with neighborhood characteristics. METHODS At a national sample of 2230 tobacco retailers in the contiguous US, we collected in-person store audit data on: Availability of products (e.g., flavored cigars), quantity of interior and exterior tobacco marketing, presence of price promotions, and marketing with youth appeal. Observational data were matched to census tract demographics. RESULTS Over 95% of stores displayed tobacco marketing; the average store featured 29.5 marketing materials. 75.1% of stores displayed at least one tobacco product price promotion, including 87.2% of gas/convenience stores and 85.5% of pharmacies. 16.8% of stores featured marketing below three feet, and 81.3% of stores sold flavored cigars, both of which appeal to youth. Stores in neighborhoods with the highest (vs. lowest) concentration of African-American residents had more than two times greater odds of displaying a price promotion (OR=2.1) and selling flavored cigars (OR=2.6). Price promotions were also more common in stores located in neighborhoods with more residents under age 18. CONCLUSIONS AND RELEVANCE Tobacco companies use retail marketing extensively to promote their products to current customers and youth, with disproportionate targeting of African Americans. Local, state, and federal policies are needed to counteract this unhealthy retail environment.

Comparing projected impacts of cigarette floor price and excise tax policies on socioeconomic disparities in smoking

Introduction Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. Methods A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits. Results Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05). Conclusions Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact. Implications Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.

Process Evaluation of an Intervention to Increase Provision of Adolescent Vaccines at School Health Centers

Background About half of all US states have cigarette minimum price laws (MPLs) that require a per cent mark-up on prices, but research suggests they may not be very effective in raising prices. An alternative type of MPL sets a floor price below which packs cannot be sold, and may be more promising. This new type of MPL policy has only been implemented in 1 city, therefore its benefits relative to excise taxes is difficult to assess. Methods We constructed a set of possible state floor price MPL options, and matched them to possible state excise tax hikes designed to produce similar average price increases. Using self-reported price and cigarette consumption data from 23 521 participants in the 2010–2011 Tobacco Use Supplement of the Current Population Survey, we projected changes in pack prices and cigarette consumption following implementation of each paired MPL and tax option, for lower and higher income groups. Results We project that state MPLs set at the average reported pack price would raise prices by