Relationship Between Alcohol Use and Violent Behavior Among Urban African American Youths From Adolescence to Emerging Adulthood: A Longitudinal Study

Objectives. We examined developmental trajectories of alcohol use and violent behavior among urban African American youths and the longitudinal relationship between these behaviors from adolescence to emerging adulthood.Methods. Our sample included 649 African American youths (49% male) followed for 8 years. We assessed violent behavior and alcohol use by asking participants how often they had engaged in each behavior in the preceding 12 months. Growth curve analyses were conducted to identify the developmental trajectories of the 2 behaviors and to explore the longitudinal relationship between them.Results. Violent behavior peaked in middle to late adolescence and declined thereafter, whereas the frequency of alcohol use increased steadily over time. These developmental trajectories varied according to gender. Among both male and female participants, early violent behavior predicted later alcohol use, and early alcohol use predicted later violent behavior. Moreover, changes in one behavior were associated with changes in the other.Conclusions. Our results support a bidirectional relationship between alcohol use and violent behavior. Efforts to reduce one problem can be expected to reduce the other. Programs and policies aimed at reducing violence or alcohol use among adolescents should take into account this relationship.Both alcohol use and violent behaviors are prevalent among urban adolescents and are important public health problems in the United States,^1,2 with violent injury being the leading cause of death among African American adolescents.³ According to a nationwide survey of high school students, 36% of students reported having committed violent acts in the preceding 12 months, and 19% reported having carried a weapon in the preceding 30 days.⁴ Another survey showed that two thirds of 12th-grade students had consumed alcohol in the past 12 months, and nearly half (45%) were current drinkers (i.e., they reported having consumed alcohol in the 30 days prior to the survey).² These problems have continued to receive increased attention in recent years.In general, 4 competing theoretical explanations have been proposed for the relationship between alcohol use and violent behavior.^5,6 According to the first model, alcohol use causes violent behavior owing to psychopharmacological effects⁷ or a criminal subculture.⁸ The second model postulates that alcohol use is caused by violent behavior and is a consequence of a violent lifestyle because aggressive individuals are more likely to select or be pushed into social situations that encourage heavy drinking.⁹The third model combines the first 2 models and argues that alcohol use and violence reinforce each other; in other words, alcohol use causes violence, and vice versa.¹⁰ The final model postulates that the relationship between alcohol use and violence is spurious.^10,11 Both behaviors are predicted by the same common set of risk factors and cluster together as a result of a single general problem behavior syndrome.^12,13The relationship between alcohol use and violence has been documented in many studies.^5,6,14 In a large number of these studies, however, alcohol use and violence have been assessed at a single time point, and lead-lag effects (one variable correlating with another variable at a subsequent point in time) could not be studied. In the few studies that have examined longitudinal associations between alcohol use and violent behavior, findings have been mixed.For example, some researchers have found that early alcohol use predicts later violent behavior,^15–18 and others have found that early violent behavior predicts later alcohol use.^11,19,20 White et al.,¹⁰ in their study of high-risk adolescent boys, demonstrated a bidirectional rather than unidirectional association between alcohol use and violent behavior. Other researchers^21–23 have also found that the relationship between alcohol use and violent behavior involves reciprocal influences.In a meta-analysis of existing longitudinal studies examining the correlations between alcohol use and violence, Lipsey et al.²⁴ found that when common risk factors were taken into account, the strengths of the relationships were attenuated. In contrast, White et al.¹⁰ found that the strengths of cross-lagged associations between alcohol and aggression were not reduced significantly when they controlled for common risk factors.One problem with existing research is that many of these studies have involved somewhat limited samples.^5,25 Some researchers draw their samples from the juvenile justice system, which may not be representative of youths more generally. Others draw their samples from schools but exclude dropouts and absentees, which may lead to undersampling of the most heavy alcohol users and delinquents. Most studies have included predominantly White youths in their samples. Little is known about the longitudinal relationship between alcohol use and violent behavior among African American youths. Perhaps most important, few studies have addressed the critical developmental period of emerging adulthood (age 18–29 years), which would allow an examination of associations between these 2 behaviors across different stages in the life cycle.The objectives of our study were to address these gaps in the literature and test the 4 competing theories on the relationship between alcohol use and violent behavior with more than 600 African American youths followed for 8 years. Because our data were collected at multiple time points, we were able to examine the developmental trajectories of these behaviors, the lead-lag relationship between alcohol use and violent behavior, and how changes in one behavior were associated with changes in the other.We investigated whether early alcohol use or violent behavior predicted later violent behavior or alcohol use from adolescence to emerging adulthood. We also examined the relationship between alcohol use and violent behavior from a developmental life course perspective in an attempt to determine whether the association differed in adolescence and emerging adulthood.Researchers have found that rates of violent behavior²⁶ and use of alcohol and other drugs²⁷ are higher among adolescent boys than among adolescent girls. Violent behavior peaks in middle to late adolescence and declines thereafter,²⁶ whereas the frequency of alcohol and other drug use continues to increase throughout adolescence and declines in emerging adulthood.²⁸ In this study, we also assessed whether the developmental trajectories of alcohol use and violent behavior and the longitudinal associations between the 2 behaviors differ according to gender.In our analyses, we controlled for several common risk factors for both alcohol use and violence described in the literature.²⁹ We included participants'' academic achievement and depressive symptoms, parental drug use and violent behavior, family conflict, and peer drug use and violent behavior, as well as whether participants had sold illegal drugs. All of these measures were assessed at wave 1 of the study unless otherwise noted. We attempted to determine whether the relationship between alcohol and violent behavior could be explained by these common risk factors.     

Pathways to Early Violent Death: The Voices of Serious Violent Youth Offenders

Quantitative studies have uncovered factors associated with early violent death among youth offenders detained in the juvenile justice system, but little is known about the contextual factors associated with pathways to early violent death among youths detained in adult jails.We interviewed young Black male serious violent youth offenders detained in an adult jail to understand their experience of violence. Their narratives reveal how the code of the street, informal rules that govern interpersonal violence among poor inner-city Black male youths, increases the likelihood of violent victimization.Youth offenders detained in adult jails have the lowest rate of service provision among all jail populations. We have addressed how services for youth offenders can be improved to reduce the pathways to early violent death.

“I carry my gun anywhere I go, I mean if I got to crush [kill or injure] someone, then I will. I don’t care. It’s either him or me.”—Ice, aged 17 years

On any given day in the United States 7600 youths younger than 18 years are detained in adult jails.1,2 Youths of color are overrepresented among this group.3 Although they represent only 17% of the total youth population, 62% of youths prosecuted in the adult criminal justice system are Black, and they are 9 times more likely than are White youths to receive an adult prison sentence.4 Serious minority male offenders are more likely to be transferred to adult court and confined to more restrictive settings.5 Research on serious violent youth offenders who were adjudicated in an adult criminal court suggests that they are at greater risk for violent injury and early violent death than are youths processed in juvenile court.6–11 Youths placed in adult jails and prisons are also at greater risk to be sexually and physically assaulted. They are the easiest prey for violent victimization and sexual abuse and so are the hardest hit,12,13 and according to the Centers for Disease Control and Prevention, they are approximately 34% more likely than are youths adjudicated in the juvenile justice system to be rearrested for a violent crime.14Although studies have documented early violent death among youth offenders detained in adult jail,6 a critical omission in this research is contextual information on why the rate of violence and homicide is so high among this population.6,10,11,15–18 Their “voices” are missing.18 Although there is a wealth of quantitative data on risk factors for early violent death among youth offenders,6 we know little about the meaning of violence in their lives and how violence shapes their social worlds. We have addressed this gap in the literature.To explore pathways to early violent death among serious violent youth offenders, we drew on the narratives of Black male adolescents transferred to adult court. We explored how these youth offenders negotiated the social context of inner-city violence while they were on the “outside.” We asked questions regarding “disrespect” as well as the following questions: Did they carry firearms? In what situations would they use a firearm? What role does violence play in their lives? How do drugs, alcohol, and violence fit into the social context of their lives and the communities where they reside? Were they chronically exposed to violence? Have they ever been violently victimized? How do they negotiate violence in the context of jail?     

Alcohol Outlets and Binge Drinking in Urban Neighborhoods: The Implications of Nonlinearity for Intervention and Policy

Objectives. Alcohol outlet density has long been associated with alcohol-related harms, and policymakers have endorsed alcohol outlet restriction to reduce these harms. However, potential nonlinearity in the relation between outlet density and alcohol consumption has not been rigorously examined.Methods. We used data from the New York Social Environment Study (n = 4000) to examine the shape of the relation between neighborhood alcohol outlet density and binge drinking by using a generalized additive model with locally weighted scatterplot smoothing, and applied an imputation-based marginal modeling approach.Results. We found a nonlinear relation between alcohol outlet density and binge drinking; the association was stronger at densities of more than 80 outlets per square mile. Binge drinking prevalence was estimated to be 13% at 130 outlets, 8% at 80 outlets, and 8% at 20 outlets per square mile.Conclusions. This nonlinearity suggests that reductions in alcohol outlet density where density is highest and the association is strongest may have the largest public health impact per unit reduction. Future research should assess the impact of policies and interventions that aim to reduce alcohol outlet density, and consider nonlinearity in effects.A substantial body of research has found that availability of alcohol, as measured by alcohol outlet density, is related to societal problems that include driving under the influence,1,2 automobile crashes,3–6 injuries,7 suicide,6 and violence.8–22 Alcohol outlet density has also been related to higher mean alcohol consumption,23–26 binge or heavy drinking,27,28 alcohol disorders,29 and liver problems.30Recent systematic reviews have concluded that the literature supports restriction of alcohol outlet density as an effective measure to reduce alcohol-related harms.31,32 Furthermore, a variety of policymaking bodies have endorsed alcohol outlet density restriction, specifically the Task Force on Community Preventive Services, the European Union, the World Health Organization, and Substance Abuse and Mental Health Services Administration.31,33–36Although the literature strongly suggests that alcohol outlet density shapes alcohol-related outcomes, most of the existing research makes the implicit assumption that the relation is essentially linear. A recent review called for research that considers the shape of the relation between alcohol outlet density and alcohol-related outcomes because the shape has practical implications for intervention and policy.31 If the relation were linear, interventions that aim to reduce alcohol outlet density at any baseline density would be equally effective. However, if the shape of the relation were nonlinear, interventions would have differing degrees of effectiveness in reducing alcohol-related harms depending on the baseline alcohol outlet density.There is a limited body of work that has considered the shape of the relation between alcohol outlet density and various outcomes. Two studies on violence assessed potential nonlinear associations with alcohol outlet density, and found stronger relations with violence at higher outlet densities.37,38 Only 1 study examined potential nonlinearity in the relation between alcohol outlet density and alcohol consumption; this study found substantially stronger relations between outlet density and harmful alcohol consumption for the highest category of outlet density. However, the use of a categorical approach (with an open-ended upper category) to examine density provides a limited assessment of the shape of the relation.39There is a need for research that rigorously examines the shape of the relation between alcohol outlet density and alcohol consumption. Building on the extant research, we examined the relation between neighborhood alcohol outlet density and binge drinking in an urban population. We examined the shape of the relation by using a semiparametric general additive model with locally weighted scatterplot smoothing (loess) instead of assuming a standard form. Then we applied a marginal modeling approach to estimate prevalences of binge drinking associated with “setting” neighborhood alcohol outlet density to levels across the range of the data.40,41     

Alcohol Environments and Disparities in Exposure Associated With Adolescent Drinking in California

Objectives. We investigated sociodemographic disparities in alcohol environments and their relationship with adolescent drinking.Methods. We geocoded and mapped alcohol license data with ArcMap to construct circular buffers centered at 14 595 households with children that participated in the California Health Interview Survey. We calculated commercial sources of alcohol in each buffer. Multivariate logistic regression differentiated the effects of alcohol sales on adolescents'' drinking from their individual, family, and neighborhood characteristics.Results. Alcohol availability, measured by mean and median number of licenses, was significantly higher around residences of minority and lower-income families. Binge drinking and driving after drinking among adolescents aged 12 to 17 years were significantly associated with the presence of alcohol retailers within 0.5 miles of home. Simulation of changes in the alcohol environment showed that if alcohol sales were reduced from the mean number of alcohol outlets around the lowest-income quartile of households to that of the highest quartile, prevalence of binge drinking would fall from 6.4% to 5.6% and driving after drinking from 7.9% to 5.9%.Conclusions. Alcohol outlets are concentrated in disadvantaged neighborhoods and can contribute to adolescent drinking. To reduce underage drinking, environmental interventions need to curb opportunities for youth to obtain alcohol from commercial sources by tightening licensure, enforcing minimum-age drinking laws, or other measures.Despite federal, state, and local interventions, underage drinking continues to be a serious problem. A national survey found that 17.6% of adolescents drank alcohol in the past 30 days, 11.1% were binge drinkers, and 2.7% were heavy drinkers.¹ Health and social problems associated with youths'' drinking include motor vehicle crashes,^2,3 violence,⁴ risky sexual behaviors,^5,6 assault and rapes,⁷ and brain impairment.^8–11 Adolescent alcohol use has substantial societal costs.¹² Drinking at an early age also increases the risk of addiction and other alcohol-related problems in adulthood.^13–15 In 2007, the surgeon general responded to this problem in the Call to Action to Prevent and Reduce Underage Drinking, which emphasized environmental contributions to the problem.¹⁶Underage drinkers obtain their alcoholic beverages from a variety of sources, including parents'' stocks, friends, parties, and commercial outlets.¹⁷ In 1 study, buyers who looked underage were able to purchase alcohol with high success rates from both on-site (for consumption on the premises, such as bars and restaurants) and off-site (for consumption elsewhere, such as liquor stores) establishments.^18,19 Sales to minors have been found to be significantly associated with the percentage of Hispanic residents in a neighborhood and with population density.²⁰As long as adolescents can obtain alcohol from commercial sources, neighborhood outlets are likely to play a role in underage drinking. Rhee et al. argued that environment plays an essential role in drinking initiation and that genetics are important in developing alcohol dependence.²¹ Perceived alcohol availability was significantly associated with higher levels of alcohol consumption among young men²² and with drinking in public locations for adolescent girls.²³ Density of outlets for alcohol in cities was associated with youths'' drinking and driving and with riding in a car driven by a person under the influence of alcohol.²⁴Differences in alcohol environments may exacerbate health disparities across sociodemographic groups. LaVeist and Wallace found that in Baltimore, MD, predominantly Black and low-income census tracts have more liquor stores per capita than do tracts of other race and income groups.²⁵ Gorman and Speer found retail liquor outlets abundantly located in poor and minority neighborhoods in a city in New Jersey.²⁶ Only 1 national study has been published, and it reported higher densities of liquor stores in zip codes with higher percentages of Blacks and lower-income non-Whites.²⁷ That study covered all urban areas in the United States, but the urban zip codes had a mean land area of 40.1 square miles and a mean population of 21 920 persons,²⁷ arguably too large to represent neighborhoods. Even census tracts may be too large and too dissimilar to capture neighborhood effects: in Los Angeles County they can range from 0.04 square miles to 322 square miles.The objectives of this study were (1) to describe the quantity and geographic pattern of alcohol retailers in small areas around individual homes and (2) to examine relationships between alcohol environments and adolescent drinking. We analyzed data from the entire state of California to investigate the effects of spatial accessibility on alcohol sales to adolescents.     

The Long-Term Health Consequences of Relationship Violence in Adulthood: An Examination of Low-Income Women From Boston, Chicago, and San Antonio

Objectives. We examined the long-term health consequences of relationship violence in adulthood.Methods. Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables.Results. Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health.Conclusions. Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.Over the past 2 decades, numerous studies have examined the long-term health consequences of relationship violence during childhood. This body of research suggests that physical and sexual abuse in early life can be devastating to health in adulthood, contributing to poor mental^1–6 and physical health^3–5,7 and to higher rates of substance abuse.^5,6,8,9 These patterns are remarkably consistent across studies and notably persistent through the life course. In a recent study of more than 21 000 older adults, Draper et al.³ reported that physical and sexual abuse before 15 years of age is associated with poor mental and physical health well into late life.Although previous research has made significant contributions to our understanding of the lasting effects of abuse in early life, few studies have considered the long-term health consequences of relationship violence in adulthood. Our review of the literature revealed 5 longitudinal studies of relationship violence and health in adulthood. Not surprisingly, research suggests that women who experience relationship violence in adulthood are vulnerable to poor health trajectories, including increases in depressive symptoms,^10–12 functional impairment,^10,12 and alcohol consumption.^13,14Relationship violence is an important issue in all segments of society; however, studies consistently show that women of low socioeconomic status exhibit higher rates of intimate partner victimization than do their more affluent counterparts.^15–17 For example, Tolman and Raphael¹⁷ reported that between 34% and 65% of women receiving welfare report having experienced some form of relationship violence in their lifetime, and between 8% and 33% experience some form of relationship violence each year, levels that surpass those for women overall.¹⁸ Research also shows that residence in disadvantaged neighborhoods^19,20 and the presence of children in the household^21,22 may elevate the odds of relationship violence. Given their high violence-risk profile, attention must be directed to the patterns and health consequences of intimate partner victimization in the lives of disadvantaged urban women with children.^23–25Building on previous research, we used data collected from a large probability sample of low-income women with children living in low-income neighborhoods in Boston, Massachusetts, Chicago, Illinois, and San Antonio, Texas, to predict changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with measures of relationship violence in early life and adulthood and a host of relevant background variables. In accordance with previous research, we expected that intimate partner victimization in adulthood would predict increases in psychological distress and the frequency of intoxication and decreases in self-rated health over the study period.     

Use of a Social and Character Development Program to Prevent Substance Use, Violent Behaviors, and Sexual Activity Among Elementary-School Students in Hawaii

Objectives. We assessed the effectiveness of a 5-year trial of a comprehensive school-based program designed to prevent substance use, violent behaviors, and sexual activity among elementary-school students.Methods. We used a matched-pair, cluster-randomized, controlled design, with 10 intervention schools and 10 control schools. Fifth-graders (N = 1714) self-reported on lifetime substance use, violence, and voluntary sexual activity. Teachers of participant students reported on student (N = 1225) substance use and violence.Results. Two-level random-effects count models (with students nested within schools) indicated that student-reported substance use (rate ratio [RR] = 0.41; 90% confidence interval [CI] = 0.25, 0.66) and violence (RR = 0.42; 90% CI = 0.24, 0.73) were significantly lower for students attending intervention schools. A 2-level random-effects binary model indicated that sexual activity was lower (odds ratio = 0.24; 90% CI = 0.08, 0.66) for intervention students. Teacher reports substantiated the effects seen for student-reported data. Dose-response analyses indicated that students exposed to the program for at least 3 years had significantly lower rates of all negative behaviors.Conclusions. Risk-related behaviors were substantially reduced for students who participated in the program, providing evidence that a comprehensive school-based program can have a strong beneficial effect on student behavior.Substance use, violent behaviors, and early initiation of sexual activity occur at problematic levels among American youths.^1–4 Early initiation of substance use and engaging in violent behaviors during childhood place children at a greater risk of psychopathology, aggressive behaviors, and continuation of substance use during adolescence and into adulthood.^5–10 National estimates have indicated that approximately 43.3% of high school students had consumed alcohol, 35.9% had been in a physical fight, and 46.8% had engaged in sexual intercourse over the previous 12 months.⁵ Thus, prevention programs that can reduce the incidence of such behaviors should provide clear public health benefits.Appropriately designed and implemented school-based prevention programs can prevent or reduce negative behaviors,^2,11,12 but some programs have not been evaluated for efficacy and effectiveness,^9,13 criteria deemed crucial in determining whether a program is ready for widespread adoption by schools.^14,15 Although studies indicate positive treatment effects for school-based prevention programs, the magnitude of effects is often modest.^16,17 The average effect size for such programs is 0.20¹⁸ (comparable to a success rate of 9.5%), suggesting that there is considerable room for improvement in the effectiveness of prevention programs in reducing negative behaviors. In addition, accumulating evidence indicates that negative behaviors do not exist in isolation from one another,^2,19 so programs that address multiple co-occurring negative behaviors are likely to be of greater overall benefit.^20,21Our goal was to evaluate the preventive benefits of the Positive Action program, a comprehensive schoolwide social and character development program. We hypothesized that the Positive Action program would result in lower rates of student substance use, violence, and voluntary sexual activity, as measured by student self-reports and teacher reports. Previous quasi-experimental studies of the Positive Action program^22,23 reported beneficial school-level effects on student achievement and serious problem behaviors (e.g., suspensions and violence). We build on previous research by reporting on a matched-pair, cluster-randomized controlled study.¹⁴ These features of a study are important when examining the scientific credibility of intervention findings.     

Alcohol advertising at Boston subway stations: an assessment of exposure by race and socioeconomic status

Objectives. We investigated the frequency of alcohol ads at all 113 subway and streetcar stations in Boston and the patterns of community exposure stratified by race, socioeconomic status, and age.Methods. We assessed the extent of alcohol advertising at each station in May 2009. We measured gross impressions and gross rating points (GRPs) for the entire Greater Boston population and for Boston public school student commuters. We compared the frequency of alcohol advertising between neighborhoods with differing demographics.Results. For the Greater Boston population, alcohol advertising at subway stations generated 109 GRPs on a typical day. For Boston public school students in grades 5 to 12, alcohol advertising at stations generated 134 GRPs. Advertising at stations in low-poverty neighborhoods generated 14.1 GRPs and at stations in high-poverty areas, 63.6 GRPs.Conclusions. Alcohol ads reach the equivalent of every adult in the Greater Boston region and the equivalent of every 5th- to 12th-grade public school student each day. More alcohol ads were displayed in stations in neighborhoods with high poverty rates than in stations in neighborhoods with low poverty rates.Excessive alcohol use is the third-leading lifestyle-related cause of death in the United States.¹ Immediate health risks include unintentional injuries,² violence,^2,3 risky sexual behaviors,^4,5 miscarriage and stillbirth among pregnant women,^6,7 fetal alcohol syndrome,⁷ and alcohol poisoning.⁸ Long-term health risks include neurological,^9,10 cardiovascular,^11,12 and psychiatric problems,¹³ as well as an increased risk of cancer,^12,14 liver disease,^12,15,16 and pancreatitis.^12,17,18 Excessive alcohol use is also linked to a variety of social problems, including increased unemployment¹⁹ and frequency of violent crime and incarceration.^20,21 Drinking among underage youths is increasing.^22–25 Excessive alcohol use also has economic consequences. Alcohol-related health care utilization (e.g., motor vehicle crashes, fires), productivity losses, social welfare (e.g., food stamps), and criminal justice cost the United States an estimated $184.6 billion in 1998 alone.^12,26Alcohol advertising has historically been linked to increased consumption of alcohol in youths,^25,27–31 and a more recent study also shows an increase in consumption by adults.³² These data come from studies of advertising in a variety of media, including television, music video, public transit, and outdoor advertising.^25–31 Alcohol is disproportionately advertised in low-income neighborhoods^33,34 and in neighborhoods with a high proportion of racial and ethnic minorities.^32,34–36Studies have shown that people of color experience poorer health outcomes and shorter life expectancies than do Whites.³⁷ Individuals of lower socioeconomic status also have been found to have higher morbidity and mortality and more risk factors for heart disease and stroke than do people of higher socioeconomic status.³⁸ Minorities are more likely to live in poverty, which exacerbates the negative consequences of alcohol use.³⁹ Because racial and ethnic minorities and individuals of lower socioeconomic status are at a higher risk for poor health and have been identified as targets of alcohol advertising, it is critical that advertising policies change to protect these disadvantaged groups. Hackbarth et al. suggest that reducing alcohol consumption among disadvantaged groups through community intervention, such as banning alcohol advertising, would be one way to eliminate such health disparities.³⁶In 2007 Kwate et al. determined that Black neighborhoods in New York City had more advertising space than White neighborhoods and that these spaces were disproportionately used to market alcohol and tobacco products.³⁵ However, they did not find a significant relationship between median income and ad density, which suggests that relative affluence did not protect Black neighborhoods from targeted outdoor advertising.Advertising on public transportation has received little attention in the literature. In 2007, a report issued by the Marin Institute documented the advertising practices of 20 public transit agencies nationwide. The report found that 2 major cities, Boston, Massachusetts and New York City, lagged far behind other cities that had policies in place to protect children from alcohol advertising.²⁵ Chicago, Illinois; Los Angeles, California; San Francisco, California; Washington, DC; and other places explicitly prohibit alcohol advertising on public transit systems. For example, San Francisco imposes a $5000 per day fine for violating advertising policies.²⁵ By contrast, the Massachusetts Bay Transit Authority (MBTA), which serves the Boston area, has no such restrictions against alcohol advertising, although it claims to prohibit all “adult-oriented goods and services.” The MBTA bans advertising that features tobacco, violence, or nudity because they are considered inappropriate for viewing by minors.²⁵ It is disturbing that one of the largest cities in the United States has not yet adopted stricter policies to protect its riders from potentially harmful alcohol ads.In 2009, Nyborn et al. studied the frequency of alcohol advertising on MBTA train cars and found that alcohol advertisers were able to reach the equivalent of nearly half of all transit passengers each day.⁴⁰ These data showed that roughly 315 000 people, or 11% of the entire adult population in the greater Boston area (Suffolk, Middlesex, and Norfolk counties; total 2008 population = 2 841 374⁴¹) may be exposed to alcohol ads on the MBTA train lines alone. However, that study focused on ads on moving trains and did not consider the frequency of alcohol ads at train stations and how this frequency might differ between neighborhoods. We expanded the focus to include train stations to investigate whether alcohol advertising targeted particular socioeconomic or racial/ethnic groups.We aimed to (1) quantify exposure to alcohol advertising at MBTA train stations among adults in the greater Boston area and among Boston public school students in grades 5 to 12 and (2) compare the frequency of alcohol ads in different MBTA train stations to determine whether minority or poor populations were disproportionately exposed.     

A Multilevel Analysis of Individual, Household, and Neighborhood Correlates of Intimate Partner Violence Among Low-Income Pregnant Women in Jefferson County, Alabama

Objectives. We examined individual, household, and neighborhood correlates of intimate partner violence (IPV) before and during pregnancy.Methods. We used multilevel modeling to investigate IPV among 2887 pregnant women in 112 census tracts who sought prenatal care in 8 public clinics in Jefferson County, Alabama, from 1997 through 2001. Data were collected from the Perinatal Emphasis Research Center project, the 2000 Census, and the local Sheriff and Police Departments Uniform Crime Reports for 1997 through 2001.Results. Participants were predominantly young, African American, on Medicaid, and residents of low-income neighborhoods. The prevalence of past-year male partner–perpetrated physical or sexual violence was 7.4%. Neighborhood residential stability, women performing most of the housework (lack of involvement among partners), being unmarried (being in an uncommitted relationship), and alcohol use were positively associated with elevated IPV risk. Significant protective factors for IPV included older age at first vaginal intercourse and a greater sense of mastery (e.g., the perception of oneself as an effective person).Conclusions. Both neighborhood contextual and individual and household compositional effects are associated with IPV among low-income pregnant women. The results imply that combined interventions to improve neighborhood conditions and strengthen families may effectively reduce IPV.Intimate partner violence (IPV) experienced by pregnant women is a public health concern in the United States because of its high prevalence and its potential for severe physical harm, including injury and death, to both the mother and unborn child. The prevalence of violence against pregnant women has been estimated at 3.9% to 8.3%, depending on the populations, specific periods of pregnancy, and screening tools.¹ Thus, an estimated 152 000 to 324 000 abused women deliver live-born infants annually.² Serious consequences of IPV include delayed prenatal care, miscarriage and spontaneous abortion, and adverse birth and child outcomes.³ Homicide was the second leading cause of injury deaths among pregnant and postpartum women,⁴ and women abused during pregnancy are 3 times more likely to be murdered over the course of their lifetime than women who were abused outside pregnancy.⁵The US Department of Health and Human Services has identified reducing the rate of physical assault by current or former intimate partners to 3.3 per 1000 persons aged 12 years and older to be a Healthy People 2010 health objective.⁶ Achieving this national goal will require further study of the factors associated with IPV, including the family characteristics that promote healthy relationships within a broad ecological systems context,^7–9 and prevention targeted at potentially accessible populations for which IPV has both serious consequences and high prevalence. More than 95% of pregnant women make routine prenatal care visits, providing a stable opportunity in the community to screen and prevent IPV within a primary care setting.^10,11 Because intimate partner violence during pregnancy occurs more often among couples of low socioeconomic status,^1,3,12 low-income households may require special attention in a community to prevent IPV experienced by pregnant women.Whereas most IPV prevention strategies focus on secondary and tertiary prevention based on identified individual-level risk factors, the national IPV prevention agenda highlights the importance of primary prevention and both contextual and protective factors for IPV.^13,14 The use of an ecological systems framework holds promise for the study of IPV because it recognizes the complexity of IPV and puts a equal, joint focus on both the male–female dyad and multiple contexts.^15,16 Prior research has identified neighborhood as an important context in understanding the prevalence of IPV. Significant neighborhood influences include low per capita income, high unemployment rate, resource deprivation, and concentrated disadvantage.^17–23 Inconsistent findings have been reported for neighborhood residential mobility and neighborhood crime.^{18,20,23–25} Compared with the contextual study of IPV in developing countries,²⁶ this line of research in the United States has benefited from a long history of social science studies examining neighborhood context and crime or delinquency.Despite providing useful insights concerning study design, theoretical perspectives, and analytical methods, previous contextual studies of IPV have important methodological limitations. One ecological study measured IPV on the neighborhood level, but did not allow inferences about IPV at the individual level.¹⁸ Other studies^{20–22,24,27,28} examined clustered data with logistic regression models, which fail to account for the clustering inherent in the data. Several studies that used multilevel modeling^17,19,23,25 had small samples with an average of about 1.6 to 2.5 study participants per neighborhood, resulting in numerous clusters with a single observation and unstable estimates of variances for binary outcomes.²⁹ Whereas some studies have underrepresented low-income households in probability samples,^{19–21,25,27,28} others have overrepresented them in convenience samples, including reported incidents from police, screened events in hospitals, and parent studies on HIV.^{17,18,22–24} One contextual study of IPV has focused on women during pregnancy and postpartum.¹⁷Improved understanding of how low-income couples can cope with environmental stressors and prevent IPV from occurring will greatly enhance the development of primary prevention programs. However, little is known about couple-level protective factors.¹³ Previous research has focused on individual- and household-level risk factors for IPV. Although IPV prevalence estimates varied by maternal race and age, consistent risk factors included low socioeconomic status, low educational attainment, and use of alcohol.^1,3,12,19 Household-level risk factors for IPV included social norms (e.g., male dominance in the family), first-time parenting, unplanned or unwanted pregnancy, lack of social support, partner drug use, poor conflict management, stress, and resource inadequacy.^{15,17,23,27,28,30}Family is the primary proximal context for human development.³¹ Strong social bonds and good marriages have been shown to reduce street crimes and IPV primarily through informal social control process.^32–40 Social bonds refer to “internalization of accepted norms, awareness, and sensitivity to the needs of others which promote conformity in society.”^40(p534) Each dimension of the bonds among partners—for example, commitment and involvement—ties partners to conventional society and societal rules, thus informally controlling and preventing IPV.^32,33,40Research designed to increase our understanding of the association of neighborhood contextual and couple-level factors with IPV among low-income pregnant women is needed. We conceptualized that IPV occurs within an ecological framework (Figure 1) that considers the interplay of neighborhood context, household factors (stressors, resources, and bonds among partners), and individual correlates of IPV. We designed this study to determine whether features of neighborhoods, being in an uncommitted relationship, and lack of involvement among partners were associated with a higher prevalence of IPV at the individual level among low-income pregnant women, when we controlled for relevant individual and household factors.Open in a separate windowFIGURE 1The ecological model of neighborhood and household contexts and influences on the experience of intimate partner violence among low-income pregnant women: Perinatal Emphasis Research Center Project, Jefferson County, Alabama, 1997–2001.Note. Solid arrows depict hypothesized strong connections between 2 domains in the sequence. Broken lines represent weaker associations. Double arrows indicate a mutual influence between 2 domains.     

Off-Premise Alcohol Sales Policies, Drinking, and Sexual Risk Among People Living With HIV

Drinking among HIV-positive individuals increases risks of disease progression and possibly sexual transmission. We examined whether state alcohol sales policies are associated with drinking and sexual risk among people living with HIV. In a multivariate analysis combining national survey and state policy data, we found that HIV-positive residents of states allowing liquor sales in drug and grocery stores had 70% to 88% greater odds of drinking, daily drinking, and binge drinking than did HIV-positive residents of other states. High-risk sexual activity was more prevalent in states permitting longer sales hours (7% greater odds for each additional hour). Restrictive alcohol sales policies may reduce drinking and transmission risk in HIV-positive individuals.More than 1 million people in the United States are living with HIV,¹ and about 56 000 people are newly infected each year.² Approximately one half of those who have had positive test results for HIV drink alcohol; about 1 in 6 regularly binge drinks.³ Drinking in this population is associated with poor treatment adherence,^4,5 disease progression,^6–8 and spread of the virus through risky sexual activity.^9–12Thus, reducing drinking and problem drinking among HIV-positive individuals is an important public health goal. Alcohol sales policies may be 1 tool for accomplishing this. Research has linked geographic variations in off-premise alcohol sales practices (e.g., regulations regarding the sale of alcohol in stores) to drinking and drinking problems in the general population.¹³ Other types of alcohol regulation have been linked to sexual health.^14–16 Sales policies may influence drinking and sexual activity by making purchases inconvenient or affecting where and when people drink.^17–20 We investigated (1) whether findings linking off-premise sales policies to drinking extend to those living with HIV (who have unique demographic characteristics, drinking patterns, and life circumstances) and (2) whether off-premise sales policies predict sexual risk behavior in this group.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Trends in Bullying,Physical Fighting,and Weapon Carrying Among 6th- Through 10th-Grade Students From 1998 to 2010: Findings From a National Study

Objectives. We examined trends from 1998 to 2010 in bullying, bullying victimization, physical fighting, and weapon carrying and variations by gender, grade level, and race/ethnicity among US adolescents.Methods. The Health Behavior in School-Aged Children surveys of nationally representative samples of students in grades 6 through 10 were completed in 1998 (n = 15 686), 2002 (n = 14 818), 2006 (n = 9229), and 2010 (n = 10 926). We assessed frequency of bullying behaviors, physical fighting, and weapon carrying as well as weapon type and subtypes of bullying. We conducted logistic regression analyses, accounting for the complex sampling design, to identify trends and variations by demographic factors.Results. Bullying perpetration, bullying victimization, and physical fighting declined from 1998 to 2010. Weapon carrying increased for White students only. Declines in bullying perpetration and victimization were greater for boys than for girls. Declines in bullying perpetration and physical fighting were greater for middle-school students than for high-school students.Conclusions. Declines in most violent behaviors are encouraging; however, lack of decline in weapon carrying merits further attention.Youth violence is a major public health concern.1,2 Even violence that does not lead directly to morbidity or mortality may have mental health consequences.3,4 Three prominent indicators of youth violence are bullying at school, physical fighting, and weapon carrying. These violent behaviors are associated with a number of negative behavioral and emotional outcomes that can last into adulthood.5–10 A recent meta-analysis of longitudinal studies found bullying perpetration and victimization were both related to involvement in violence in the future.8 Bullying and being a victim of bullying have also been found to predict depression and criminal offenses later in life.5,7 A prospective longitudinal twin study in England found that frequent bullying victimization in childhood increased risk of self-harm.11 Finally, a meta-analysis found that both victimized bullies and victims had higher risk for psychosomatic problems (such as aches, sleeping problems, poor appetite, bedwetting, and feeling tense) than noninvolved children.6In cross-sectional studies, physical fighting and weapon carrying have been associated with an increased likelihood of injury that required medical attention.12 Physical fighting has also been concurrently associated with mental health problems, substance use, school adjustment problems, and violent crime.10 Similarly, correlates of weapon carrying include substance use13–15 and property offenses.16The national Youth Risk Behavior Surveillance Survey (YRBS) biennially assesses violent behaviors among 9th- through 12th-grade students. Bullying has only been assessed since 2009 and is limited to having been a victim of bullying on school property or having been bullied electronically. There has been no change in bullying victimization from 2009 to 2011.17 Physical fighting and weapon carrying have been assessed since 1991. Physical fighting declined from 1991 to 2009, with no significant change from 2009 to 2011.17 Weapon carrying declined from 1991 to 1999 but there has been no significant decrease since 1999.17 Other than YRBS, there has been only 1 other nationally representative study of trends in violent behavior in the United States. Molcho et al.18 examined trends in bullying and victimization in 11-, 13-, and 15-year-old adolescents in 27 European countries and the United States from 1994 to 2006 (only from 1998 to 2006 in the United States). They found a significant decrease in all measures of bullying (occasional and chronic victimization and bullying) among boys in the United States but no change among girls. However, they did not examine violent behaviors other than bullying and the sample was not adequate for testing differences in trends by characteristics other than gender.No studies to date have presented trends in bullying, being the victim of a bully (hereafter referred to as victimization), physical fighting, and weapon carrying among US students before high school. The current study expands on the work by Molcho et al.18 by examining more indicators of violent behavior in students aged 11 through 16 years with samples adequate for examining racial/ethnic, gender, and school-grade differences through 2010. It also expands on the YRBS data17 by including students in grades 6 through 8 (as young as 11 years), more waves of data when assessing trends in bullying and bullying perpetration, and testing for differences in trends by gender, race/ethnicity, and grade in school. Little is known about trends in violent behaviors among younger adolescents, where bullying is more prevalent.19 The 2 objectives of the current study were (1) to examine the trends in prevalence of bullying, physical fighting, and weapon carrying in US children and adolescents from grades 6 through 10 spanning 12 years (1998–2010); and (2) to test for variations by gender, grade, and race/ethnicity.     

Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

Objectives. In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes.Methods. Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants.Results. Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization.Conclusions. Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.The risk of violence associated with mental illnesses is a topic of research, media coverage, and debate. Research indicates that between 11% and 52% of adults with mental illnesses have been violent within a 12-month period,1–7 and data from the National Comorbidity Survey show that rates of violence for adults with mental illnesses are 2 to 8 times greater than in the general population.8 Other studies show modest but significant relationships between mental illness and violence,3,9,10 even after controlling for substance abuse.11 Although highly publicized cases of violence perpetrated by adults with mental illnesses have highlighted their “dangerousness,” data suggest they experience victimization at rates comparable to or higher than their rates of perpetration.12 Studies show 12-month prevalence rates between 20% and 44%,7,12–15 and indicate the likelihood of experiencing violent victimization is 23 times higher in adults with mental illnesses compared with the general population.12 Despite these findings, there remains a focus on violence perpetration to the neglect of victimization in this vulnerable population.The increased risk of violent outcomes that is associated with mental illnesses represents a substantial public health burden. Violence can be devastating to victims and perpetrators alike, as well as being costly to the public.16,17 In addition to physical injury, violence may precipitate the loss of personal liberty because of incarceration18 or civil commitment,19 require implementation of expensive clinical and risk assessment and management strategies,20 perpetuate the stigma associated with mental illness,21 and disrupt continuity of care.22 Consequently, an understanding of the prevalence and nature of community violence—both perpetration and victimization—among adults with mental illnesses is critical to public health research and practice.Unfortunately, the empirical literature is limited. First, there are many more studies of perpetration than victimization; a review of the literature found 3 times as many publications about the link between mental illness and violence compared with the link between mental illness and victimization.23 Second, although they are risk factors for each other,24–26 there have been few studies of community violence perpetration and victimization. Only a handful of peer-reviewed publications report on both outcomes in the same sample of adults with mental illnesses during the same reference period.27–30 Third, studies that have examined both outcomes have restricted power and generalizability because of the relatively small, nonrepresentative samples. Fourth, there is heterogeneity in the operational definitions of violence, preventing meaningful comparisons or aggregation of findings. Fifth, violent outcomes are frequently measured with a single yes or no question (e.g., “Have you been victimized in the past 12 months?”), a measurement approach with limited sensitivity.31     

Previous Violent Events and Mental Health Outcomes in Guatemala

Objectives. We analyzed a probability sample of Guatemalans to determine if a relationship exists between previous violent events and development of mental health outcomes in various sociodemographic groups, as well as during and after the Guatemalan Civil War.Methods. We used regression modeling, an interaction test, and complex survey design adjustments to estimate prevalences and test potential relationships between previous violent events and mental health.Results. Many (20.6%) participants experienced at least 1 previous serious violent event. Witnessing someone severely injured or killed was the most common event. Depression was experienced by 4.2% of participants, with 6.5% experiencing anxiety, 6.4% an alcohol-related disorder, and 1.9% posttraumatic stress disorder (PTSD). Persons who experienced violence during the war had 4.3 times the adjusted odds of alcohol-related disorders (P < .05) and 4.0 times the adjusted odds of PTSD (P < .05) compared with the postwar period. Women, indigenous Maya, and urban dwellers had greater odds of experiencing postviolence mental health outcomes.Conclusions. Violence that began during the civil war and continues today has had a significant effect on the mental health of Guatemalans. However, mental health outcomes resulting from violent events decreased in the postwar period, suggesting a nation in recovery.For 36 years Guatemala experienced a violent civil war in which over 200 000 civilians were killed, 440 villages destroyed, and more than 1 million Guatemalans displaced, both internally and into southern Mexico.1–3 Those killed included indigenous persons, laborers, academics, religious leaders, and others who were clearly noncombatants.3,4 In 1996, peace accords were signed between a number of rurally based guerrilla forces and Guatemala’s national army.Nearly three quarters of the people in the world’s poorest societies have recently been through a civil war or are still in one. The average civil war lasts approximately 5 years and can be embedded in a societal context that fuels the longevity of the conflict itself by marking it as culturally “normal.”5–7 Because of cultural normalization and numerous other factors, both within and outside of Guatemala, the Guatemalan Civil War far exceeded the length of the average national civil war and might have long-standing implications for the safety and health of Guatemalans today.Civil wars produce a legacy of postconflict violence and disease,7–12 and Guatemala is no exception. Today, the northern triangle of Central America, which includes Guatemala, Honduras, and El Salvador, is described as the most violent area of the world outside of active theaters of war.3,13 Less than a decade after the civil war peace accords were signed in Guatemala, persistent violence reportedly resulted in the second highest rates of fear from armed crime in the world and the proliferation of more private security personnel than members of the regular army.3,14 Approximately at the same time, some 1500 Guatemalan Civil War refugees living in Mexico reported alarmingly high levels of depression, anxiety, and posttraumatic stress disorder (PTSD).15 The World Health Organization (WHO) also reported elevated alcohol use disorders in Guatemala in the years following the civil war.16 These indicators occurred alongside reports that 40% of the country continued to have no mental health services, leaving many Guatemalans, repatriated refugees, and affected citizens, who remained throughout the civil war without a key aspect of care on the road to national recovery.17In dealing with the effects of civil conflicts, such as recurring violence, PTSD, depression, anxiety, alcohol abuse, and other mental health issues, postconflict societies like Guatemala face difficult decisions between enacting extraordinary military spending3,5 or provisions of enhanced social and public health services.7,18 However, policymakers in Guatemala (and internationally) have limited population-level and epidemiologic evidence19 with which to make such decisions. With this in mind, we completed the first national probability sample of the mental health of Guatemalans still living in Guatemala. We analyzed these survey data to obtain nationally representative estimates of the prevalence of select mental health problems in Guatemala,9,11,15 and to determine if a relationship existed between previous violent events and the development of subsequent mental health outcomes. We compared different sociodemographic groups,20–25 as well as the periods before and after the signing of the 1996 civil war peace accords.     

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department.Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence.Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months.Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status.^1–3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV^4–6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD.^7–11Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates.¹² High rates of PTSD have also been found among HIV-positive women,^3,13,14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV).^3,13,14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD,¹⁵ a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population¹⁶ and the PTSD rate (4.6%) in a nationally representative sample of female crime victims.¹⁷The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months.¹⁸ Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships.¹⁸ The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex.¹⁹The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD.Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD,^20–22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission.^3,23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex,^24–38 sexual practices leading to a high risk of sexually transmitted infections,^6,32,39–42 sex with multiple partners,^31,32,43 trading of sex for money or drugs,^40,44 sex with risky partners,^38,45 and sex with HIV-positive partners.³⁸ Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD^46,47 and engaging in a range of HIV risk behaviors.^48–51We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexual HIV risk behaviors in a random sample of 241 women attending an emergency department in a low-income neighborhood of the Bronx, New York. We hypothesized that women who met the criteria for PTSD and the symptom clusters of hyperarousal, reexperiencing trauma, or avoidance would be more likely than women who did not meet these criteria to engage in sexual HIV risk behaviors after adjustment and matching for potentially confounding factors such as sociodemographic characteristics, childhood sexual abuse, substance abuse, and IPV.     

The effect of tobacco outlet density and proximity on smoking cessation

Objectives. We examined the influence of tobacco outlet density and residential proximity to tobacco outlets on continuous smoking abstinence 6 months after a quit attempt.Methods. We used continuation ratio logit models to examine the relationships of tobacco outlet density and tobacco outlet proximity with biochemically verified continuous abstinence across weeks 1, 2, 4, and 26 after quitting among 414 adult smokers from Houston, Texas (33% non-Latino White, 34% non-Latino Black, and 33% Latino). Analyses controlled for age, race/ethnicity, partner status, education, gender, employment status, prequit smoking rate, and the number of years smoked.Results. Residential proximity to tobacco outlets, but not tobacco outlet density, provided unique information in the prediction of long-term, continuous abstinence from smoking during a specific quit attempt. Participants residing less than 250 meters (P = .01) or less than 500 meters (P = .04) from the closest tobacco outlet were less likely to be abstinent than were those living 250 meters or farther or 500 meters or farther, respectively, from outlets.Conclusions. Because residential proximity to tobacco outlets influences smoking cessation, zoning restrictions to limit tobacco sales in residential areas may complement existing efforts to reduce tobacco use.Although the prevalence of smoking has decreased substantially over the past few decades, smoking remains the leading cause of preventable death and disability among adults in the United States.¹ A key public health strategy to reduce the deleterious health effects of tobacco use is to decrease the prevalence of smoking by increasing smoking cessation rates.² Previous public health and policy approaches to affect smoking prevalence have included restrictions on tobacco advertising, counter-advertising campaigns, bans on smoking in public places, increases in federal and state cigarette excise taxes, and increases in the availability of treatment programs. The effectiveness of these approaches in increasing smoking cessation rates has been supported by the literature.^3–5 However, additional tobacco control strategies are needed to achieve national public health goals.²One potential area of expansion for tobacco control policies is the regulation of tobacco retail outlets. Regulation strategies are designed to facilitate behavior change by altering structural aspects of the community context in which problematic behavior occurs.⁶ An analogous area in which regulation strategies have been applied is alcohol beverage retail outlets. In this case, regulation strategies have included the implementation of zoning restrictions to reduce the density of alcohol outlets and the proximity of alcohol outlets to residential areas. It was hypothesized that such regulations would affect problematic alcohol use at a community level by decreasing residents’ access to alcohol, reducing exposure to on-site product marketing, and changing social norms about alcohol use.⁷ Ultimately, research supported the success of these policies in reducing problematic alcohol use and alcohol-related injury, crimes, and violence.^7–9 In contrast to the alcohol arena, little attention has been paid thus far to the potential utility of tobacco outlet regulation strategies as a supplement to existing tobacco control policies.The Family Smoking Prevention and Tobacco Control Act, signed into law in June 2009, greatly expands the federal government''s ability to enact new public health policies related to tobacco sales in the United States. If one considers the success of alcohol outlet regulation strategies on curbing alcohol use, an increased understanding of the effects of tobacco retail outlets on smoking behaviors may provide direction to emerging tobacco control policies. Thus far, studies largely support associations between tobacco retail outlets and smoking behaviors. For example, the density of tobacco retail outlets around schools has been linked to adolescent smoking initiation¹⁰ and purchasing habits.¹¹ Similarly, the density of tobacco outlets around the home, as well as the proximity of tobacco outlets to the home, has been associated with the number of cigarettes consumed per day among adult smokers.¹² In another study, greater smoker sensitivity to point-of-sale advertising at tobacco outlets predicted a reduced likelihood of having quit smoking 18 months later.¹³ However, no previous studies have directly examined the effects of tobacco outlet density and proximity on smoking cessation during a specific quit attempt.The purpose of our study was to examine the effect of tobacco retail outlet density and proximity on smoking cessation among a racially/ethnically diverse group of smokers undergoing a specific quit attempt. We had two hypotheses. The first was that greater density of tobacco outlets around participants’ homes would be associated with lower odds of cessation. The second was that close residential proximity to a tobacco retail outlet would be associated with lower odds of cessation. All analyses controlled for participant demographics and tobacco-related variables. To our knowledge, this is the first study to examine the effects of tobacco retail outlets on a smoking quit attempt using a prospective, longitudinal design and biochemically verified smoking abstinence.     

Association Between Residential Exposure to Outdoor Alcohol Advertising and Problem Drinking Among African American Women in New York City

We evaluated the association between residential exposure to outdoor alcohol advertising and current problem drinking among 139 African American women aged 21 to 49 years in Central Harlem, New York City. We found that exposure to advertisements was positively related to problem drinking (13% greater odds), even after we controlled for a family history of alcohol problems and socioeconomic status. The results suggest that the density of alcohol advertisements in predominantly African American neighborhoods may add to problem drinking behavior of their residents.Substantial literature shows that alcohol advertisements are disproportionately located in African American neighborhoods.^1–3 Much of this research was conducted in the 1990s, and it was argued that the alcohol industry''s marketing strategies targeted 2 vulnerabilities in the African American community: “high aspirations for upward mobility at one end, and social despair and a general lack of economic vitality at the other.”^4(p454) In the 1980s, given the economic deprivation associated with urban African American enclaves, the proliferation of advertising at that time has been described as a blatant attempt to profit from human misery.⁵ Today, outdoor advertisements promote alcohol as a means to realize social mobility and reproduce stereotypical narratives about African American individuals.⁶ Taken together, the targeted marketing of health-damaging products has been described as a form of institutional racism,⁷ and community activists have resisted their proliferation.⁸Large-scale econometric data on the effects of advertising on alcohol intake are mixed,⁹ but neighborhood-level research suggests that the local alcohol environment affects behavior. Studies have shown that the density of alcohol retail outlets is associated with heavy drinking among college students¹⁰ and negative outcomes, including violence and injury.¹¹ However, to date, researchers have not studied the effects of outdoor advertising on the alcohol intake of residents in African American neighborhoods. We addressed this gap in knowledge by investigating whether exposure to alcohol advertisements is related to problem drinking among African American women.     

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

Objectives. We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India.Methods. Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants.Results. Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child.Conclusions. Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. India''s widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.Suicide is a public health priority in India. Rates of suicide in India are 5 times higher than in the developed world,^1,2 with particularly high rates of suicide among young women.^3–5 Verbal autopsy surveillance from southern India suggests that suicide accounts for 50% to 75% of all deaths among young women, with average suicide rates of 158 per 100 000.²Common mental disorders such as depressive and anxiety disorders, and social disadvantage such as gender-based violence and poverty, are major risk factors for suicide among women.^1,3,6–8 Although research from high-income countries shows that common mental disorders are a major contributor to the risk of suicidal behavior, their role is less clear in low- and middle-income countries in which social disadvantage has been found to be at least as important.^1,3,6–8 Gender disadvantage is increasingly seen as an important contributing factor to the high rates of suicide seen among women in Asia.^1,3,6,7 Gender-based violence is a common manifestation of gender disadvantage and has been linked with common mental disorders and suicide in population-based studies of women and young adults in Goa, India.^4,5,9 Lack of autonomy, early sexual debut, limited sexual choices, poor reproductive health, and social isolation are other manifestations of gender disadvantage.Sex work in India is common. An estimated 0.6% to 0.7% of the female adult urban population are engaged in commercial sexual transactions.¹⁰ Studies from developed nations have found a high prevalence of self-harming behaviors in people engaged in transactional sexual activity.¹¹ There is also growing evidence suggesting that HIV-positive individuals from traditionally stigmatized groups report higher rates of violence exposure and suicidal ideation.^12,13 Female sex workers in India are a traditionally stigmatized group, with high prevalence of HIV¹⁰ and levels of stigma and violence that relate to the context of their work.¹⁴ Yet, despite substantial investigation of their reproductive and sexual health needs, there is virtually no information on suicide and its determinants among female sex workers from low- and middle-income countries.¹⁵As demonstrated in the hierarchical conceptual framework outlined in Figure 1,^4,5,9 we hypothesized that gender disadvantage, sex work, and health factors together with factors indicative of social disadvantage are distal determinants of female sex workers'' vulnerability to suicidal behaviors,^4,5,9,15 the effects of which would be mediated though poor mental health.³ We studied the burden of suicidal behaviors in a cross-sectional sample of female sex workers in Goa, India. We explored the association of sociodemographic factors, type of sex work, sexual health, and gender disadvantage, with and without measures of poor mental health, on suicide attempts in the past 3 months.Open in a separate windowFIGURE 1A conceptual framework for social risk factors for suicide among female sex workers in India.Note. STI = sexually transmitted infection.     

Income Inequality,Alcohol Use,and Alcohol-Related Problems

Objectives. We examined the relationship between state-level income inequality and alcohol outcomes and sought to determine whether associations of inequality with alcohol consumption and problems would be more evident with between-race inequality measures than with the Gini coefficient. We also sought to determine whether inequality would be most detrimental for disadvantaged individuals.Methods. Data from 2 nationally representative samples of adults (n = 13 997) from the 2000 and 2005 National Alcohol Surveys were merged with state-level inequality and neighborhood disadvantage indicators from the 2000 US Census. We measured income inequality using the Gini coefficient and between-race poverty ratios (Black–White and Hispanic–White). Multilevel models accounted for clustering of respondents within states.Results. Inequality measured by poverty ratios was positively associated with light and heavy drinking. Associations between poverty ratios and alcohol problems were strongest for Blacks and Hispanics compared with Whites. Household poverty did not moderate associations with income inequality.Conclusions. Poverty ratios were associated with alcohol use and problems, whereas overall income inequality was not. Higher levels of alcohol problems in high-inequality states may be partly due to social context.A growing literature examines the impact of area-level income inequality on health. Inequality, or the size of the difference in income between rich and poor, is distinct from absolute income or socioeconomic status (SES).1 Recent systematic reviews have found associations between income inequality and health.2–6 Theoretical3,7 and empirical work suggests that income inequality may affect health through psychosocial pathways, whereby people compare themselves with those who are better (or worse) off,4,8–10 and neomaterial pathways, whereby inequality leads to limited public investment in social goods such as education, health services, and welfare that directly affect health.3,11,12 (The term “neomaterial” is used to acknowledge the fact that material conditions relevant to present-day health outcomes differ from those material conditions that influenced infectious diseases in the 19th century.3)Most research on income inequality and health has focused broadly on health status and mortality,2 but a few studies focus on specific health outcomes and health behaviors.2,13,14 Among these is a small literature on alcohol that suggests that income inequality is associated with increased frequency of alcohol consumption,13 volume of alcohol consumed,14,15 drinking to drunkenness,14 and death from chronic alcohol-attributable illnesses.16 Results are not unequivocal, however. Findings for alcoholic cirrhosis are mixed, with one study finding a positive association for men but not women15 and others finding no association.17,18 Another study documented a curvilinear relationship with alcohol-related hospitalization, suggesting an initial decline in hospitalizations followed by a rapid rise as inequality increases.16 Finally, one study found that state-level income inequality was negatively associated with women’s alcohol dependence, but not after adjustment for state beer taxes.19To date, this literature on income inequality and alcohol has not examined whether income inequality affects alcohol consumption and related problems equally across SES and race/ethnicity. Furthermore, it has primarily measured income inequality using the Gini coefficient, a measure that captures the difference between an observed income distribution and a condition of complete equality.1 We have expanded on the existing literature by examining SES and race/ethnicity as moderators of associations between income inequality and alcohol outcomes, and by examining race-based measures of income inequality in addition to the Gini coefficient.Income inequality may not affect everyone in the same way.2,20 Affluent individuals may benefit from2 or be immune to the negative effects of²¹ living in unequal areas, whereas poorer people and Black and Hispanic people may suffer a “double jeopardy” in unequal areas.20,21 This double jeopardy hypothesis, however, may be specific to certain health and social outcomes.18 For example, compared with more egalitarian areas, areas with more unequal income distribution have stronger inverse associations between individual SES and adolescent literacy21 as well as mortality from alcoholic liver disease.18 These studies indicate that there is an interaction of individual SES and income inequality for certain outcomes. By contrast, some evidence suggests largely uniform (rather than differential) effects of income inequality on poor self-rated health22; however, most alcohol studies have not examined possible moderators of effects of income inequality.Income inequality can be measured overall or by comparing the status of 2 groups. Overall measures incorporate the range and distribution of incomes with the extent of inequality. The most commonly used overall measure is the Gini coefficient.1 By contrast, relative measures emphasize income or poverty differences between groups based on demographic characteristics. For example, between-race income inequality measures summarize differentials in income between various racial/ethnic groups living in the same area and have been used in the criminology literature.23,24 In the United States, there are stark differences in income and poverty status between Whites, Blacks, and Hispanics. In 2000, the ratio of per capita income of Whites to Blacks was 1.66 and of Whites to Hispanics was 1.97, with 15% of Whites, almost 30% of Blacks, and more than 20% of Hispanics having family incomes below the federal poverty threshold.25 Use of these relative measures seems especially relevant given our interest in examining whether race/ethnicity moderates the associations between income inequality and alcohol outcomes.We examined whether income inequality, measured by the Gini coefficient and 2 between-race measures, is associated with light to moderate alcohol consumption, heavy alcohol consumption, alcohol-related consequences, and alcohol dependence. Although not tested explicitly here, heavy (but not light) alcohol consumption may be linked to income inequality primarily through the psychosocial pathway (such as drinking to cope with stress), whereas alcohol problems additionally may be influenced by neomaterial effects of inequality (such as increased policing24 or decreased funding for alcohol treatment services). We also investigated whether associations with inequality were most detrimental for disadvantaged individuals (people in poor neighborhoods, with low household income, or racial/ethnic minority status), which also may suggest neomaterial effects of inequality.3     

Prevalence of Abuse and Violence Before,During, and After Pregnancy in a National Sample of Canadian Women

Objectives. We describe the prevalence of abuse before, during, and after pregnancy among a national population-based sample of Canadian new mothers.Methods. We estimated prevalence, frequency, and timing of physical and sexual abuse, identified category of perpetrator, and examined the distribution of abuse by social and demographic characteristics in a weighted sample of 76 500 (unweighted sample = 6421) Canadian mothers interviewed postpartum for the Maternity Experiences Survey (2006–2007).Results. Prevalence of any abuse in the 2 years before the interviews was 10.9% (6% before pregnancy only, 1.4% during pregnancy only, 1% postpartum only, and 2.5% in any combination of these times). The prevalence of any abuse was higher among low-income mothers (21.2%), lone mothers (35.3%), and Aboriginal mothers (30.6%). In 52% of the cases, abuse was perpetrated by an intimate partner. Receiving information on what to do was reported by 61% of the abused mothers.Conclusions. Large population-based studies on abuse around pregnancy can facilitate the identification of patterns of abuse and women at high risk for abuse. Before and after pregnancy may be particularly important times to monitor risk of abuse.The World Health Organization (WHO) defines violence against women as

any act of gender-based violence that results in, or is likely to result in physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.1

This definition is based on the United Nations Declaration on the Elimination of Violence Against Women,2 which affirms that “violence against women constitutes a violation of the rights and fundamental freedoms of women and impairs or nullifies their enjoyment of those rights and freedoms.”2^(p1)Despite the fact that many countries signed this declaration, violence against women still persists in many developed and developing nations.1 It is a global public health concern as it puts many women at severe risk for their health and lives.3,4 Among women of reproductive age, violence has been associated with a range of adverse health and pregnancy problems and outcomes such as unwanted pregnancy,5,6 maternal pregnancy complications,7,8 lower birth weight and preterm birth,9–11 perinatal morbidity,12 maternal physical health problems,13 abortions,14 higher utilization of health care services,15 postpartum depression,16 substance abuse,17 and suicide.18 Socially vulnerable women with low income and low education, unmarried or not cohabitating,19 and at younger age,20 are at higher risk for abuse.Despite 4 decades of research, however, including hundreds of studies on violence against women in North America, sound estimates of the prevalence of abuse and violence toward women during the childbearing period are difficult to obtain. A recent systematic review of research on violence against pregnant women reported that prevalence varied widely across studies, from a low of 0.9% to a high of 21%.21 In Canada, population-based studies showed that physical violence during pregnancy was 6.6% in Ontario,22 5.7% in Saskatoon,23 and 1.2% in Vancouver.24 Such wide-ranging estimates are not useful to policymakers and program planners designing services to address this critical public health problem.Prevalence variability across studies is due in part to a variety of factors related to study design. Antenatal clinic-based samples, which are the norm for this type of research,17,25–31 may not be representative of the general population, leading to variations in estimates if, for example, women are predominantly from urban clinic samples or low-income patient populations.19,24,32,33 Response rates vary widely across studies, from a low of 17%27 to a high of 97%30; samples with lower response rates may overrepresent low-risk women.Modes of inquiry used to assess abuse also vary widely, making comparison across studies a challenge. Although use of face-to-face interviews is common in studies from developing countries, and phone interviews and mailed surveys are often used in developed counties,34 community-based surveys33 and self-administered assessments have also been employed.30 Studies have shown that women have different levels of comfort in disclosing abuse depending on the mode of inquiry, with phone and self-administered methods facilitating disclosure.35–37 Assessment tools also vary in their coverage of behaviors that constitute partner violence.37–40 Thus, myriad study design features have influenced the population prevalence rates reported in studies and their generalizability.In summary, few studies on abuse during pregnancy employ large population-based samples of women that enable a presentation of prevalence by subgroups and include rich information about the type, timing, frequency, and severity of abuse and the perpetrators involved. We build on the existing literature on abuse and perpetration patterns using a Canadian national sample of new mothers who were asked about abuse prior to and during pregnancy, as well as in the first several months postpartum.Our objectives were to estimate the prevalence, frequency, timing, and types of physical abuse before, during, and after pregnancy; to identify the category of perpetrator; and to examine the onset and cessation of abuse around pregnancy among a national representative sample of mothers who participated in the Maternity Experiences Survey (MES).     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.