Aims: We evaluated the effects of a community organizing intervention, Communities Mobilizing for Change on Alcohol (CMCA), on the propensity of retail alcohol outlets to sell alcohol to young buyers without age identification and on alcohol acquisition behaviors of underage youth. Design: Random assignment of community to treatment (n = 3) or control (n = 2). Student surveys were conducted four times per year for 3 years; the cohort was in 9th and 10th grades in the 2012–13 academic year. Alcohol purchase attempts were conducted every 4 weeks at alcohol retailers in each community (31 repeated waves). Setting: The Cherokee Nation, located in northeastern Oklahoma, USA. Participants: A total of 1399 high school students (50% male; 45% American Indian) and 113 stores licensed to sell alcohol across five study communities. Intervention: Local community organizers formed independent citizen action teams to advance policies, procedures and practices of local institutions in ways to reduce youth access to alcohol and foster community norms opposed to teen drinking. Measurements: Perceptions regarding police enforcement and perceived difficulty of and self-reported actual acquisition of alcohol from parents, adults, peers and stores. Findings: Alcohol purchases by young-appearing buyers declined significantly, an 18 [95% confidence interval (CI) = 3, 33] percentage-point reduction over the intervention period. Student survey results show statistically significant differences in the trajectory of perceived police enforcement, increasing 7 (4, 10) percentage points, alcohol acquisition from parents, decreasing 4 (0.1, 8) percentage points, acquisition from 21+ adults, decreasing 6 (0.04, 11) percentage points, from < 21 peers decreasing 8 (3, 13) percentage points and acquisition from stores decreasing 5 (1, 9) percentage points. Conclusions: A community organizing intervention, Communities Mobilizing for Change on Alcohol (CMCA), is effective in reducing the availability of alcohol to underage youth in the United states. Furthermore, results indicate that the previously reported significant effects of CMCA on teen drinking operate, at least in part, through effects on alcohol access.

Purpose: Health disparities persist in birth outcomes by mother's income, education, and race in the United States. Disadvantaged mothers may experience benefit from supplements to family income, such as the earned income tax credit (EITC). We examined the effects of state-level EITCs on birth outcomes among women with a high school education or less, stratified by race and ethnicity. Methods: A quasi-experimental multistate and multiyear difference-in-differences design is used to assess effects of the presence and generosity of 23 state-level EITC laws on birth outcomes from 1994 to 2013. The methods utilized the U.S. National Vital Statistics System birth data for the outcomes: birth weight, probability of low birth weight (LBW; <2500 g), and gestation weeks. Results: Across all subgroups, any level of state EITC is associated with better birth outcomes with the largest effects seen among states with more generous EITCs. Black mothers experience larger percentage point reductions in the probability of LBW and increases in gestation duration. Among mothers with a high school education or less, results translate into 3760 fewer LBW babies with black mothers and 8364 fewer LBW babies with white mothers per year at the most generous state EITC level (i.e., 10% or more of federal and refundable). Hispanic and non-Hispanic mothers display relatively similar effects. Conclusions: The EITC at the federal and state level is an effective policy tool to reduce poverty and improve birth outcomes across racial and ethnic subgroups. Given the historically higher risk among black mothers, state-level EITC expansions offer one policy option to address this persistent health disparity.

Despite substantial declines since the 1960's, heart disease remains the leading cause of death in the United States (US) and geographic disparities in heart disease mortality have grown. State-level socioeconomic factors might be important contributors to geographic differences in heart disease mortality. This study examined the association between state-level minimum wage increases above the federal minimum wage and heart disease death rates from 1980 to 2015 among ‘working age’ individuals aged 35–64 years in the US. Annual, inflation-adjusted state and federal minimum wage data were extracted from legal databases and annual state-level heart disease death rates were obtained from CDC Wonder. Although most minimum wage and health studies to date use conventional regression models, we employed marginal structural models to account for possible time-varying confounding. Quasi-experimental, marginal structural models accounting for state, year, and state × year fixed effects estimated the association between increases in the state-level minimum wage above the federal minimum wage and heart disease death rates. In models of ‘working age’ adults (35–64 years old), a $1 increase in the state-level minimum wage above the federal minimum wage was on average associated with ~6 fewer heart disease deaths per 100,000 (95% CI: −10.4, −1.99), or a state-level heart disease death rate that was 3.5% lower per year. In contrast, for older adults (65+ years old) a $1 increase was on average associated with a 1.1% lower state-level heart disease death rate per year (b = −28.9 per 100,000, 95% CI: −71.1, 13.3). State-level economic policies are important targets for population health research.

For the past 25 years, I have led multiple group-randomized trials, each focused on a specific underserved population of youth and each one evaluated health effects of complex interventions designed to prevent high-risk behaviors. I share my reflections on issues of intervention and research design, as well as how research results fostered my evolution toward addressing fundamental social determinants of health and well-being. Reflections related to intervention design emphasize the importance of careful consideration of theory of causes and theory of change, theoretical comprehensiveness versus fundamental determinants of population health, how high to reach, and health in all policies. Flowing from these intervention design issues are reflections on implications for research design, including the importance of matching the unit of intervention to the unit of assignment, the emerging field of public health law research, and consideration of design options and design elements beyond and in combination with random assignment.

Poverty has numerous deleterious effects on health, and the Earned Income Tax Credit (EITC) is the major policy tool used to alleviate poverty in the U.S. We evaluate effects of four distinct changes in earned income tax credit law in Washington, DC on maternal behaviors and infant outcomes. An interrupted time-series design was used with 312 monthly measures from 1990 through 2015 analyzed in 2018 (total n = 225,933 births). States with no EITC were included as the comparison group; analyses involved ARIMA modeling. Outcomes were derived from birth certificates, and included percent of live births below 2500 g, mean birth weight, mean gestation weeks, first trimester prenatal care, and maternal smoking during pregnancy. We found a pattern of significant improvements across all three infant outcome measures, with the size of the effect estimate monotonically matching the magnitude of the tax credit—ranging from a 1.9 (-2.9, -0.9) reduction in rate per 100 births of low birth weight for the smaller 10% credit, to a 4.7 (-5.4, -4.0) reduction with the 40% credit. Results for maternal smoking and prenatal care were mixed. Results suggest that earned income tax credit policies improve birth outcomes; mechanisms for this effect deserve further study.

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003–2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

Background: Despite concerns over measurement error, self-report continues to be the most common measure of adolescent alcohol use used by researchers. Objective measures of adolescent alcohol use continue to advance; however, they tend to be cost prohibitive for larger studies. By combining appropriate statistical techniques and validation subsamples, the benefits of objective alcohol measures can be made more accessible to a greater number of researchers. Objectives: To compare three easily implemented methods to correct for measurement error when objective measures of alcohol use are available for a subsample of participants, regression calibration, multiple imputation for measurement error (MIME), and probabilistic sensitivity analysis (PSA), and provide guidance regarding the use of each method in scenarios likely to occur in practice. Methods: This simulation experiment compared the performance of each method across different sample sizes, both differential and non-differential error, and differing levels of sensitivity and specificity of the exposure measure. Results: Failure to adjust for measurement error led to substantial bias across all simulated scenarios ranging from a 35% to 208% change in the log-odds. For non-differential misclassification, regression calibration reduced this bias to between a 1% and 23% change in the log-odds regardless of sample size. At higher sample sizes, MIME produced approximately unbiased (between a 0% and 9% change in the log-odds) and relatively efficient corrections for both non-differential and differential misclassification. PSA provided little utility for correcting misclassification due to the inefficiency of its estimates. Conclusion: Concern over measurement error resulting from self-reported adolescent alcohol use persists in research. Where appropriate, methods involving validity subsamples provide an efficient avenue for addressing these concerns.

This ecologic cohort study explores the relationship between state minimum wage laws and rates of HIV diagnoses among heterosexual black residents of U.S metropolitan areas over an 8-year span. Specifically, we applied hierarchical linear modeling to investigate whether state-level variations in minimum wage laws, adjusted for cost-of-living and inflation, were associated with rates of new HIV diagnoses among heterosexual black residents of metropolitan statistical areas (MSAs; n=73), between 2008 and 2015. Findings suggest that an inverse relationship exists between baseline state minimum wages and initial rates of newly diagnosed HIV cases among heterosexual black individuals, after adjusting for potential confounders. MSAs with a minimum wage that was $1 higher at baseline had a 27.12% lower rate of newly diagnosed HIV cases. Exploratory analyses suggest that income inequality may mediate this relationship. If subsequent research establishes a causal relationship between minimum wage and this outcome, efforts to increase minimum wages should be incorporated into HIV prevention strategies for this vulnerable population.

Background: Alcohol is a recognized risk factor for sexually transmitted diseases acquisition, but the mechanism is unclear. Potentially, adolescents using alcohol in the 2 hours before sex (in-the-moment use) have riskier sexual partners. Methods: We used multivariable logistic regression to examine the association between in-the-moment alcohol use and partner risk characteristics reported for the most recent sex among primarily 17- to 18-year-old adolescents originally recruited from a representative sample of Chicago public elementary schools. We created 3 composite partner risk profiles: partner familiarity risk (casual and unexpected), partner context risk (age discordance and met in public), and overall risk using all measures except partner alcohol use. Results: Teens who reported any in-the-moment alcohol use were more likely than nondrinking teens to report casual (adjusted odds ratio [AOR], 3.2; 95% confidence interval [95% CI] , 2.1-4.9), unexpected (AOR, 1.6; 95% CI, 1.0-2.5), age discordant (AOR, 3.0; 95% CI, 2.0-4.6), or met in public partners (AOR, 1.4; 95% CI, 1.0 to 2.1). For each composite measure, the number of partner risk characteristics reported increased linearly with the percent of teens drinking in the moment (Cochran-Armitage trend, P < 0.0001). Compared with zero characteristics, in-the-moment alcohol use was associated with increased odds of reporting 1 (AOR, 2.8; 95% CI, 1.7-4.5), 2 (AOR, 4.6; 95% CI, 2.7, 7.6), or 3 to 4 characteristics (AOR, 7.1; 95% CI, 3.3-15.3). Conclusions: Our findings expand the link between in-the-moment alcohol use and partner risk reported in prior studies to encompass adolescents' general sexual experiences and additional partner characteristics including the highly associated composite characteristics.

The purpose of this paper is to investigate the effects of state-level Earned Income Tax Credit (EITC) laws in the U.S. on maternal health behaviors and infant health outcomes. Using multi-state, multi-year difference-in-differences analyses, we estimated effects of state EITC generosity on maternal health behaviors, birth weight and gestation weeks. We find little difference in maternal health behaviors associated with state-level EITC. In contrast, results for key infant health outcomes of birth weight and gestation weeks show small improvements in states with EITCs, with larger effects seen among states with more generous EITCs. Our results provide evidence for important health benefits of state-level EITC policies.