1. The neighborhood social
environment shapes mental
health and health behavior
Social Determinants of Urban Mental Health
September 19, 2012
Chicago, IL
Jennifer Ahern, PhD
University of California, Berkeley

2. Overview
• Introduction
• Community social environment
– Violence
– Depression
– Smoking
• Discussion

3. Introduction
• Research on community characteristics that shape
health has been an area of particular focus in social
epidemiology over past 20 years
– Intuition
– Evidence

4. Intuition

5. Intuition

6. Intuition

7. Evidence

8. Evidence

9. Evidence
• Geographic levels
– Nations
– States
– Communities or neighborhoods
• Different geographic levels have distinct relevant
exposures
• Plausible community level exposures
– Social interactions
– Availability of goods and services
– Land use, built environment

10. Community social environment
• My work on community factors and health
– Social environment
• Collective efficacy
• Norms
– Outcomes of mental health and health behaviors
• Violence
• Depression
• Smoking

11. • Violence

12. Communities and violence
• A modern perspective on the community factors that
shape violence in the United States emerged from
sociological work in Chicago
• Historical processes marginalized and isolated
communities and produced conditions of structural
disadvantage
– Segregation
– Redlining
– Poor educational opportunities
– Transfer of manufacturing jobs overseas
Shaw and McKay 1942, Kornhauser 1978, Wilson 1987, Massey 1996; Sampson et al. 1997

13. Communities and violence
• Collective efficacy
– Introduced as a construct that might capture the social capacity
that deteriorates in communities that have been marginalized
and isolated
– Deterioration of collective efficacy could lead to violence
– Definition: group members shared belief in their collective ability
to produce desired results
– Encompasses two components
• Social cohesion - mutual trust and shared values
• Informal social control - willingness to intervene for the common
good
Bandura 1986, 2001; Sampson et al. 1997

14. Communities and violence
• Chicago researchers postulated that the combination of
mutual trust and willingness to intervene was a critical
capacity for controlling violent behavior
• Collective efficacy
– Strongly associated with violent crime
– Key link between indicators of structural disadvantage and
violent crime
Sampson et al. 1997

15. Communities and violence
• Further research in Chicago has found relations of
collective efficacy with
– Youth firearm carrying
– Dating violence victimization
– Adolescent suicide attempts
• Studies have documented relations between collective
efficacy and violence elsewhere in the world
– Stockholm, Sweden
– Brisbane, Australia
• Need to examine collective efficacy violence relations in
other United States urban settings
Molnar et al. 2004; Jain et al. 2010; Maimon et al 2010; Sampson et al. 2007; Mazerolle et al. 2010

16. Communities and violence
• Examined the relation between neighborhood
collective efficacy and violence in New York City

17. NYSES
• New York Social Environment Study (NYSES)
• Telephone survey of 4000 adult NYC residents
– June to December 2005
• Neighborhoods
– 59 community districts, headed by community boards
– 19-144 survey respondents per neighborhood

18. NYSES Respondents and NYC Neighborhoods

19. NYSES
NYSES Population (N=4000) 2000 Census
N % %
Age
18-24 350 11.8 13.2
25-34 685 18.1 22.5
35-44 815 19.5 20.8
45-54 808 21.4 16.7
55-64 612 14.9 11.3
≥ 65 690 14.4 15.5
Race
White 1616 38.2 38.7
African American 1055 27.0 23.0
Asian 164 5.1 10.1
Hispanic 958 27.2 24.7
Other 95 2.5 3.6
Sex
Male 1880 48.9 46.2
Female 2120 51.1 53.8

20. Communities and violence
• Collective efficacy
– Social cohesion: neighbors are close-knit, are helpful, get along,
share values, are trustworthy
– Informal social control: neighbors would intervene if children
skipped school, children sprayed graffiti, children disrespected
an adult, there were a fight, the city were closing a firehouse
– Project on Human Development in Chicago Neighborhoods
(PHDCN) scale
– Neighborhood measure is average of responses of residents
(alpha=0.77)
Sampson 1997

21. Communities and violence
• Violence
– “In the past 12 months, has anyone used violence, such as in a
mugging, fight, or sexual assault, against you or any member of
your household anywhere in your neighborhood?”
– Captures interpersonal community violence
Sampson 1997; Krug et al. 2002

22. Communities and violence
• Confounders/covariates:
– Demographic and socioeconomic characteristics
– Individual perception of collective efficacy
• Generalized estimating equation (GEE) logistic
regression models to account for clustering by
neighborhood

23. Communities and violence
• Marginal modeling approach
– Estimate relations on the additive scale that is
relevant to public health
Greenland 1993; Ahern 2009

24. Communities and violence
• Collective efficacy
– Mean 3.5, range 2.7-4.0
– 3: on average respondents “neither agree nor
disagree” that the neighborhood is cohesive, etc.
– 4: on average respondents “somewhat agree” that the
neighborhood is cohesive, etc.
• Violence reported by 5.9%

25. Communities and violence
• Multivariable logistic regression analyses of
relation between collective efficacy and violence
– OR = 4.9, 95% CI: 2.7, 9.2

26. Communities and violence
• Marginal modeling approach
– What prevalence of violence would we expect to
observe under high collective efficacy vs. low
collective efficacy

27. Communities and violence
• Set collective efficacy across the range of values
in the neighborhoods observed
– Estimated prevalence of violence if all neighborhoods
had collective efficacy = 3 compared with collective
efficacy = 4
– θ(a) = EW{E[Y|A=a,W]}
• Where A is collective efficacy and it is set to the value a, W is
the vector of confounders and Y is the prevalence of violence

28. Communities and violence
θ(3) θ(4) θ(3-4) 95% CI
Violence 11.4% 2.7% 8.7% 4.6%, 13.8%

29. Communities and violence
• Strong relations of collective efficacy with
violence
– Conservatively adjusted model
– Results conducted with homicide data similar
– Robust to sensitivity analysis
• Collective efficacy without respondents reporting violence
• Adjustment for neighborhood socioeconomic status

30. • Depression

31. Communities and depression
• Collective efficacy conceptualized as a social capacity
that shapes violence, but may influence other health
outcomes such as depression
– Informal social control – willingness to intervene for the common
good
• Reduce actual or perceived potential for stressful events to occur in the
community
– Social cohesion – mutual trust and shared values
• Provide social support and integration to residents
• Buffer effects of stressful events when they occur
Kim 2008; Cultrona 2006

32. Communities and depression
• Small set of studies on collective efficacy (or related
constructs) find lower collective efficacy is related to
more depression or depression symptoms in the United
States
– Less consistent results from other countries – may be due to less
egalitarian society with fewer safety nets in United States
• However existing studies have not parsed out individual
perception of collective efficacy from community
collective efficacy
– Particular concern for depression because of negative affect
Mair 2009; Echeverria 2008; Gary 2007; Ross 2000

33. Communities and depression
• Examined the relation between neighborhood
collective efficacy and depression

34. Communities and depression
• Neighborhood collective efficacy – PHDCN
scale
• Depression
– Patient Health Questionnaire-9 (PHQ-9)
• Positive screen for major depression: 5 or more of 9
symptoms, one must be depressed mood or anhedonia
• 73% sensitivity and 98% specificity compared with
physician diagnosis
Spitzer 1999; Kroenke 2001

35. Communities and depression
• Confounders/covariates
– Demographic and socioeconomic characteristics
– Individual perception of collective efficacy
– Stressors that might instigate a move and cause depression
(e.g., financial problems, unemployment)
• GEE logistic models and marginal models

36. Communities and depression
• Current depression positive screen 3.7%

37. Communities and depression
• Marginal modeling approach
– What prevalence of depression would we expect to
observe if all neighborhoods had collective efficacy =
3 compared with collective efficacy = 4

38. Communities and depression
θ(3) θ(4) θ(3-4) 95% CI
All 4.2% 4.3% -0.1% -3.1%, 3.1%
Age group
18-24 7.0% 2.7% 4.3% -1.7%, 14.3%
25-64 2.9% 5.0% -2.1% -5.0%, 1.0%
≥ 65 8.2% 2.0% 6.2% 0.1%, 17.5%

39. Communities and depression
• Strong relation between collective efficacy and
depression among those 65 years and older
– Recent research suggests individuals with limited
mobility more affected by community environment
– Conservatively adjusted model
– Robust to sensitivity analysis
• Collective efficacy without respondents reporting depression
• Adjustment for neighborhood socioeconomic status
Vallee 2011

40. • Smoking

41. Communities and smoking
• Collective efficacy may influence health behaviors such
as smoking
– Social cohesion – mutual trust and shared values
• Less social support and integration may lead to worse mental health
and subsequent smoking
• More social support and integration may lead to more contact with
others facilitating transmission of norms around smoking
– Informal social control – willingness to intervene for the
common good
• More social control may lead to more enforcement of norms around
smoking
Bandura 2000; Durkheim 1897; Shaw 1942

42. Communities and smoking
• Smoking norms
– Norms about use may be transmitted through
observation of behavior
– Members of a community may pressure one another
to conform to acceptable smoking behavior
Greiner 2004; Jencks 1990; Stead 2001

43. Communities and smoking
• Qualitative research suggests combined effect of
collective efficacy and norms on substance use
– Strong community norms foster smoking and
undermine cessation
– Strong support networks and community identity
seem to encourage rather than challenge smoking
Stead 2001

44. Communities and smoking
• Examined the separate and combined relations
of neighborhood collective efficacy and
neighborhood smoking norms with smoking
behavior

45. Communities and smoking
• Hypothesis on combined relation
– High collective efficacy neighborhoods with weaker
norms against smoking will have the highest use
– High collective efficacy neighborhoods with stronger
norms against smoking will have the lowest use

46. Communities and smoking
• Neighborhood collective efficacy – PHDCN scale
• Neighborhood smoking norms
– Opinion on adults smoking cigarettes regularly
• acceptable, unacceptable, don’t care
– Neighborhood measure is proportion that believe it is
“unacceptable”
Sampson 1997, PHDCN, NSDUH & ESAP

47. Communities and smoking
• World Mental Health Comprehensive
International Diagnostic Interview (WMH CIDI)
tobacco section
– Smoking in past year
– Smoking history (e.g., age first tried, age first smoked
regularly)

48. Communities and smoking
• Confounders/covariates
– Demographic and socioeconomic characteristics
– Individual perception of collective efficacy and individual smoking
norm
– History of smoking prior to residence in current neighborhood
• GEE logistic models and marginal models

49. Communities and smoking
• Neighborhood smoking norms
– Mean 59%, Range 43%-76%
– On average, 59% respondents disapprove of regular
smoking among adults
• Smoking prevalence 20.4%

50. Communities and smoking
• Marginal models – θ(low-high)
– Collective efficacy and smoking
• θ(3-4) = 2.6/100, 95% CI: -3.4, 8.5
– Smoking norms and smoking
• θ(49%-69%) = 3.3/100, 95% CI: 0.4, 6.5

51. 0.15
Communities and smoking
Es mated difference in smoking prevalence associated with
0.1
neighborhood smoking norms
0.05
0
Tried smoking Weekly/daily smoker Never tried smoking
-0.05
-0.1

52. 0.2
0.18 Where smoking norms are
permissive, high collective efficacy
0.16 is associated with more smoking
Estimated Smoking Prevalence
0.14
0.12
Norms Prohibitive
0.1
Norms Mid
Norms Permissive
0.08
0.06
0.04 Where norms are strong against
smoking, high collective efficacy is
0.02 associated with less smoking
0
Collective Efficacy Low Collective Efficacy Mid Collective Efficacy High
Sub-group “never tried smoking” before lived in neighborhood

53. Communities and smoking
• No evidence of an association between neighborhood
collective efficacy alone and current smoking
• Neighborhood smoking norms were associated with
current smoking
• Combined association of norms and collective efficacy
with smoking
– Association present in those with no history of smoking prior to
residence in the current neighborhood
• Conservatively adjusted model
• Robust to sensitivity analysis
– Adjustment for neighborhood socioeconomic status

54. Discussion
• Research suggests that collective efficacy may play a
role in shaping violence, depression and smoking
– All findings independent of individual perception of the
community
– Implies likely impacts on broader health outcomes (e.g., health
impacts of smoking)
• Combinations of community characteristics may be
critical to understanding how they shape health
– Example of collective efficacy and smoking norms
– Combinations of social and physical environment?
– Challenges of collinearity

55. Discussion

56. Discussion
• Causal challenges
– Attempted to disentangle social selection from social causation,
but limited due to lack of longitudinal or intervention data
Past health or Current
health health
determinants
(unmeasured)
?
Neighborhood

57. Discussion
• Individuals may live in particular neighborhoods based on reasons
that are related to health
– Expensive medical bills lead to a move to an area with less expensive
housing
– Historical processes (e.g., segregation) restricted where people with
different social and economic characteristics were able to live
– Any underlying factor that determines both neighborhood of residence
and health creates a selection process
• Neighborhood characteristics are associated with current health, but
this may be due to selection
• Concern that we are not able to measure and control for everything
that relates to selection

58. Discussion
• Intervention…
– Well London – community randomized trial targeting community
engagement, physical and social environment
• Aim to improve physical activity, healthy eating, and mental
wellbeing
– Youth Action Research for Prevention – youth empowerment
intervention targeting collective efficacy, educational
expectations
• Aim to reduce drug and sex risk behavior
– Pilot training program to facilitate community members ability to
intervene in neighborhood problems
• Aim to reduce violence
Phillips 2012; Berg 2009; Ohmer 2010

59. Discussion
• Intervention to build collective efficacy needs to consider
its origins in complex historical processes
– Must go beyond targeting interpersonal interactions and also
facilitate connections outside targeted communities to reduce the
marginalization and provide access to needed resources and
services
Sampson 1997; Sabol 2004

60. References
• Ahern J, Cerda M, Lippman S, Tardiff K, Vlahov D, Galea S.
Navigating non-positivity in neighborhood studies: an analysis of
collective efficacy and violence. J Epidemiol Community Health
2012. Epub.
• Ahern J, Galea S. Collective efficacy and major depression in urban
neighborhoods. Am J Epidemiol 2011;173:1453-1462.
• Ahern J, Galea S, Hubbard A, Syme SL. Neighborhood smoking
norms modify the relation between collective efficacy and smoking
behavior. Drug Alcohol Depend 2009;100:138-145.
• Ahern J, Hubbard A, Galea S. Estimating the effects of potential
public health interventions on population disease burden: a step-by-
step illustration of causal inference methods. Am J Epidemiol
2009;169:1140-1147.

61. Acknowledgments
• Funding provided by the National Institutes of Health (DA017642)
• Sandro Galea, MD DrPH
• David Vlahov, PhD
• Alan Hubbard, PhD
• S. Leonard Syme, PhD