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Panel Discussion: State-of-the-Art Research: Jennifer Ahern, Ph.D.

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Panel Discussion: State-of-the-Art Research: Jennifer Ahern, Ph.D. Panel Discussion: State-of-the-Art Research: Jennifer Ahern, Ph.D. Presentation Transcript

  • The neighborhood social environment shapes mental health and health behaviorSocial Determinants of Urban Mental Health September 19, 2012 Chicago, IL Jennifer Ahern, PhD University of California, Berkeley
  • Overview• Introduction• Community social environment – Violence – Depression – Smoking• Discussion
  • Introduction• Research on community characteristics that shape health has been an area of particular focus in social epidemiology over past 20 years – Intuition – Evidence
  • Intuition
  • Intuition
  • Intuition
  • Evidence
  • Evidence
  • Evidence• Geographic levels – Nations – States – Communities or neighborhoods• Different geographic levels have distinct relevant exposures• Plausible community level exposures – Social interactions – Availability of goods and services – Land use, built environment
  • Community social environment• My work on community factors and health – Social environment • Collective efficacy • Norms – Outcomes of mental health and health behaviors • Violence • Depression • Smoking
  • • Violence
  • Communities and violence• A modern perspective on the community factors that shape violence in the United States emerged from sociological work in Chicago• Historical processes marginalized and isolated communities and produced conditions of structural disadvantage – Segregation – Redlining – Poor educational opportunities – Transfer of manufacturing jobs overseasShaw and McKay 1942, Kornhauser 1978, Wilson 1987, Massey 1996; Sampson et al. 1997
  • Communities and violence• Collective efficacy – Introduced as a construct that might capture the social capacity that deteriorates in communities that have been marginalized and isolated – Deterioration of collective efficacy could lead to violence – Definition: group members shared belief in their collective ability to produce desired results – Encompasses two components • Social cohesion - mutual trust and shared values • Informal social control - willingness to intervene for the common goodBandura 1986, 2001; Sampson et al. 1997
  • Communities and violence• Chicago researchers postulated that the combination of mutual trust and willingness to intervene was a critical capacity for controlling violent behavior• Collective efficacy – Strongly associated with violent crime – Key link between indicators of structural disadvantage and violent crimeSampson et al. 1997
  • Communities and violence• Further research in Chicago has found relations of collective efficacy with – Youth firearm carrying – Dating violence victimization – Adolescent suicide attempts• Studies have documented relations between collective efficacy and violence elsewhere in the world – Stockholm, Sweden – Brisbane, Australia• Need to examine collective efficacy violence relations in other United States urban settingsMolnar et al. 2004; Jain et al. 2010; Maimon et al 2010; Sampson et al. 2007; Mazerolle et al. 2010
  • Communities and violence• Examined the relation between neighborhood collective efficacy and violence in New York City
  • NYSES• New York Social Environment Study (NYSES)• Telephone survey of 4000 adult NYC residents – June to December 2005• Neighborhoods – 59 community districts, headed by community boards – 19-144 survey respondents per neighborhood
  • NYSES Respondents and NYC Neighborhoods
  • NYSES NYSES Population (N=4000) 2000 Census N % %Age 18-24 350 11.8 13.2 25-34 685 18.1 22.5 35-44 815 19.5 20.8 45-54 808 21.4 16.7 55-64 612 14.9 11.3 ≥ 65 690 14.4 15.5Race White 1616 38.2 38.7 African American 1055 27.0 23.0 Asian 164 5.1 10.1 Hispanic 958 27.2 24.7 Other 95 2.5 3.6Sex Male 1880 48.9 46.2 Female 2120 51.1 53.8
  • Communities and violence• Collective efficacy – Social cohesion: neighbors are close-knit, are helpful, get along, share values, are trustworthy – Informal social control: neighbors would intervene if children skipped school, children sprayed graffiti, children disrespected an adult, there were a fight, the city were closing a firehouse – Project on Human Development in Chicago Neighborhoods (PHDCN) scale – Neighborhood measure is average of responses of residents (alpha=0.77)Sampson 1997
  • Communities and violence• Violence – “In the past 12 months, has anyone used violence, such as in a mugging, fight, or sexual assault, against you or any member of your household anywhere in your neighborhood?” – Captures interpersonal community violenceSampson 1997; Krug et al. 2002
  • Communities and violence• Confounders/covariates: – Demographic and socioeconomic characteristics – Individual perception of collective efficacy• Generalized estimating equation (GEE) logistic regression models to account for clustering by neighborhood
  • Communities and violence• Marginal modeling approach – Estimate relations on the additive scale that is relevant to public healthGreenland 1993; Ahern 2009
  • Communities and violence• Collective efficacy – Mean 3.5, range 2.7-4.0 – 3: on average respondents “neither agree nor disagree” that the neighborhood is cohesive, etc. – 4: on average respondents “somewhat agree” that the neighborhood is cohesive, etc.• Violence reported by 5.9%
  • Communities and violence• Multivariable logistic regression analyses of relation between collective efficacy and violence – OR = 4.9, 95% CI: 2.7, 9.2
  • Communities and violence• Marginal modeling approach – What prevalence of violence would we expect to observe under high collective efficacy vs. low collective efficacy
  • Communities and violence• Set collective efficacy across the range of values in the neighborhoods observed – Estimated prevalence of violence if all neighborhoods had collective efficacy = 3 compared with collective efficacy = 4 – θ(a) = EW{E[Y|A=a,W]} • Where A is collective efficacy and it is set to the value a, W is the vector of confounders and Y is the prevalence of violence
  • Communities and violence θ(3) θ(4) θ(3-4) 95% CIViolence 11.4% 2.7% 8.7% 4.6%, 13.8%
  • Communities and violence• Strong relations of collective efficacy with violence – Conservatively adjusted model – Results conducted with homicide data similar – Robust to sensitivity analysis • Collective efficacy without respondents reporting violence • Adjustment for neighborhood socioeconomic status
  • • Depression
  • Communities and depression• Collective efficacy conceptualized as a social capacity that shapes violence, but may influence other health outcomes such as depression – Informal social control – willingness to intervene for the common good • Reduce actual or perceived potential for stressful events to occur in the community – Social cohesion – mutual trust and shared values • Provide social support and integration to residents • Buffer effects of stressful events when they occurKim 2008; Cultrona 2006
  • Communities and depression• Small set of studies on collective efficacy (or related constructs) find lower collective efficacy is related to more depression or depression symptoms in the United States – Less consistent results from other countries – may be due to less egalitarian society with fewer safety nets in United States• However existing studies have not parsed out individual perception of collective efficacy from community collective efficacy – Particular concern for depression because of negative affectMair 2009; Echeverria 2008; Gary 2007; Ross 2000
  • Communities and depression• Examined the relation between neighborhood collective efficacy and depression
  • Communities and depression• Neighborhood collective efficacy – PHDCN scale• Depression – Patient Health Questionnaire-9 (PHQ-9) • Positive screen for major depression: 5 or more of 9 symptoms, one must be depressed mood or anhedonia • 73% sensitivity and 98% specificity compared with physician diagnosisSpitzer 1999; Kroenke 2001
  • Communities and depression• Confounders/covariates – Demographic and socioeconomic characteristics – Individual perception of collective efficacy – Stressors that might instigate a move and cause depression (e.g., financial problems, unemployment)• GEE logistic models and marginal models
  • Communities and depression• Current depression positive screen 3.7%
  • Communities and depression• Marginal modeling approach – What prevalence of depression would we expect to observe if all neighborhoods had collective efficacy = 3 compared with collective efficacy = 4
  • Communities and depression θ(3) θ(4) θ(3-4) 95% CIAll 4.2% 4.3% -0.1% -3.1%, 3.1%Age group 18-24 7.0% 2.7% 4.3% -1.7%, 14.3% 25-64 2.9% 5.0% -2.1% -5.0%, 1.0% ≥ 65 8.2% 2.0% 6.2% 0.1%, 17.5%
  • Communities and depression• Strong relation between collective efficacy and depression among those 65 years and older – Recent research suggests individuals with limited mobility more affected by community environment – Conservatively adjusted model – Robust to sensitivity analysis • Collective efficacy without respondents reporting depression • Adjustment for neighborhood socioeconomic statusVallee 2011
  • • Smoking
  • Communities and smoking• Collective efficacy may influence health behaviors such as smoking – Social cohesion – mutual trust and shared values • Less social support and integration may lead to worse mental health and subsequent smoking • More social support and integration may lead to more contact with others facilitating transmission of norms around smoking – Informal social control – willingness to intervene for the common good • More social control may lead to more enforcement of norms around smokingBandura 2000; Durkheim 1897; Shaw 1942
  • Communities and smoking• Smoking norms – Norms about use may be transmitted through observation of behavior – Members of a community may pressure one another to conform to acceptable smoking behaviorGreiner 2004; Jencks 1990; Stead 2001
  • Communities and smoking• Qualitative research suggests combined effect of collective efficacy and norms on substance use – Strong community norms foster smoking and undermine cessation – Strong support networks and community identity seem to encourage rather than challenge smokingStead 2001
  • Communities and smoking• Examined the separate and combined relations of neighborhood collective efficacy and neighborhood smoking norms with smoking behavior
  • Communities and smoking• Hypothesis on combined relation – High collective efficacy neighborhoods with weaker norms against smoking will have the highest use – High collective efficacy neighborhoods with stronger norms against smoking will have the lowest use
  • Communities and smoking• Neighborhood collective efficacy – PHDCN scale• Neighborhood smoking norms – Opinion on adults smoking cigarettes regularly • acceptable, unacceptable, don’t care – Neighborhood measure is proportion that believe it is “unacceptable”Sampson 1997, PHDCN, NSDUH & ESAP
  • Communities and smoking• World Mental Health Comprehensive International Diagnostic Interview (WMH CIDI) tobacco section – Smoking in past year – Smoking history (e.g., age first tried, age first smoked regularly)
  • Communities and smoking• Confounders/covariates – Demographic and socioeconomic characteristics – Individual perception of collective efficacy and individual smoking norm – History of smoking prior to residence in current neighborhood• GEE logistic models and marginal models
  • Communities and smoking• Neighborhood smoking norms – Mean 59%, Range 43%-76% – On average, 59% respondents disapprove of regular smoking among adults• Smoking prevalence 20.4%
  • Communities and smoking• Marginal models – θ(low-high) – Collective efficacy and smoking • θ(3-4) = 2.6/100, 95% CI: -3.4, 8.5 – Smoking norms and smoking • θ(49%-69%) = 3.3/100, 95% CI: 0.4, 6.5
  • 0.15 Communities and smokingEs mated difference in smoking prevalence associated with 0.1 neighborhood smoking norms 0.05 0 Tried smoking Weekly/daily smoker Never tried smoking -0.05 -0.1
  • 0.2 0.18 Where smoking norms are permissive, high collective efficacy 0.16 is associated with more smoking Estimated Smoking Prevalence 0.14 0.12 Norms Prohibitive 0.1 Norms Mid Norms Permissive 0.08 0.06 0.04 Where norms are strong against smoking, high collective efficacy is 0.02 associated with less smoking 0 Collective Efficacy Low Collective Efficacy Mid Collective Efficacy HighSub-group “never tried smoking” before lived in neighborhood
  • Communities and smoking• No evidence of an association between neighborhood collective efficacy alone and current smoking• Neighborhood smoking norms were associated with current smoking• Combined association of norms and collective efficacy with smoking – Association present in those with no history of smoking prior to residence in the current neighborhood• Conservatively adjusted model• Robust to sensitivity analysis – Adjustment for neighborhood socioeconomic status
  • Discussion• Research suggests that collective efficacy may play a role in shaping violence, depression and smoking – All findings independent of individual perception of the community – Implies likely impacts on broader health outcomes (e.g., health impacts of smoking)• Combinations of community characteristics may be critical to understanding how they shape health – Example of collective efficacy and smoking norms – Combinations of social and physical environment? – Challenges of collinearity
  • Discussion
  • Discussion• Causal challenges – Attempted to disentangle social selection from social causation, but limited due to lack of longitudinal or intervention data Past health or Current health health determinants (unmeasured) ? Neighborhood
  • Discussion• Individuals may live in particular neighborhoods based on reasons that are related to health – Expensive medical bills lead to a move to an area with less expensive housing – Historical processes (e.g., segregation) restricted where people with different social and economic characteristics were able to live – Any underlying factor that determines both neighborhood of residence and health creates a selection process• Neighborhood characteristics are associated with current health, but this may be due to selection• Concern that we are not able to measure and control for everything that relates to selection
  • Discussion• Intervention… – Well London – community randomized trial targeting community engagement, physical and social environment • Aim to improve physical activity, healthy eating, and mental wellbeing – Youth Action Research for Prevention – youth empowerment intervention targeting collective efficacy, educational expectations • Aim to reduce drug and sex risk behavior – Pilot training program to facilitate community members ability to intervene in neighborhood problems • Aim to reduce violencePhillips 2012; Berg 2009; Ohmer 2010
  • Discussion• Intervention to build collective efficacy needs to consider its origins in complex historical processes – Must go beyond targeting interpersonal interactions and also facilitate connections outside targeted communities to reduce the marginalization and provide access to needed resources and servicesSampson 1997; Sabol 2004
  • References• Ahern J, Cerda M, Lippman S, Tardiff K, Vlahov D, Galea S. Navigating non-positivity in neighborhood studies: an analysis of collective efficacy and violence. J Epidemiol Community Health 2012. Epub.• Ahern J, Galea S. Collective efficacy and major depression in urban neighborhoods. Am J Epidemiol 2011;173:1453-1462.• Ahern J, Galea S, Hubbard A, Syme SL. Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior. Drug Alcohol Depend 2009;100:138-145.• Ahern J, Hubbard A, Galea S. Estimating the effects of potential public health interventions on population disease burden: a step-by- step illustration of causal inference methods. Am J Epidemiol 2009;169:1140-1147.
  • Acknowledgments• Funding provided by the National Institutes of Health (DA017642)• Sandro Galea, MD DrPH• David Vlahov, PhD• Alan Hubbard, PhD• S. Leonard Syme, PhD