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1.  Genderedness of bar drinking culture and alcohol-related harms: A multi-country study 
This study explores whether associations between consuming alcohol in bars and alcohol-related harms are consistent across countries and whether country-level characteristics modify associations. We hypothesized that genderedness of bar drinking modifies associations, such that odds of harms associated with bar drinking increase more rapidly in predominantly male bar-drinking countries. Multilevel analysis was used to analyze survey data from 21 countries representing five continents from Gender, Alcohol, and Culture: An International Study (GENACIS). Bar frequency was positively associated with harms overall. Relationships between bar frequency and harms varied across country. Genderedness modified associations between bar frequency and odds of fights, marriage/relationship harms, and work harms. Findings were significant only for men. Contrary to our hypothesis, odds of harms associated with bar drinking increased less rapidly in countries where bar drinking is predominantly male. This suggests predominantly male bar drinking cultures may be protective for males who more frequently drink in bars.
doi:10.1007/s11469-012-9398-x
PMCID: PMC3660036  PMID: 23710158
gender; alcohol consumption; bars; multinational perspectives
2.  Macro-level gender equality and alcohol consumption: A multi-level analysis across U.S. States 
Higher levels of women’s alcohol consumption have long been attributed to increases in gender equality. However, only limited research examines the relationship between gender equality and alcohol consumption. This study examined associations between five measures of state-level gender equality and five alcohol consumption measures in the United States. Survey data regarding men’s and women’s alcohol consumption from the 2005 Behavioral Risk Factor Surveillance System were linked to state-level indicators of gender equality. Gender equality indicators included state-level women’s socioeconomic status, gender equality in socioeconomic status, reproductive rights, policies relating to violence against women, and women’s political participation. Alcohol consumption measures included past 30-day drinker status, drinking frequency, binge drinking, volume, and risky drinking. Other than drinker status, consumption is measured for drinkers only. Multi-level linear and logistic regression models adjusted for individual demographics as well as state-level income inequality, median income, and % Evangelical Protestant/Mormon. All gender equality indicators were positively associated with both women’s and men’s drinker status in models adjusting only for individual-level covariates; associations were not significant in models adjusting for other state-level characteristics. All other associations between gender equality and alcohol consumption were either negative or non-significant for both women and men in models adjusting for other state-level factors. Findings do not support the hypothesis that higher levels of gender equality are associated with higher levels of alcohol consumption by women or by men. In fact, most significant findings suggest that higher levels of equality are associated with less alcohol consumption overall.
doi:10.1016/j.socscimed.2012.02.017
PMCID: PMC4086912  PMID: 22521679
Alcohol consumption; Gender equality; Woman’s role; United States
3.  Whether men or women are responsible for size of gender gap in alcohol consumption depends on alcohol measure: A study across U.S. states 
Contemporary drug problems  2012;39(2):195.
Smaller gender differences in alcohol consumption are often interpreted to mean something about women’s drinking, for example, that women are increasing consumption to men’s levels. However, prior research is unclear. This study sought to determine whether variation in size of gender differences in alcohol consumption across U.S. states was due to male or female consumption. Data from the 2005 Behavioral Risk Factor Surveillance System were used to test the hypothesis that variation in size of gender differences would be associated with women’s, but not men’s consumption. Pearson’s correlations examined associations between gender-specific values of and gender differences in consumption in each state. The size of gender difference was associated with proportion of female, but not male, drinkers. Conversely, size of gender difference was associated with male frequency, five-plus frequency, volume, and risky drinking, but not female frequency, five-plus frequency, volume, or risky drinking. These findings suggest that smaller gender differences in cross-sectional studies cannot be interpreted as due to women’s alcohol consumption.
PMCID: PMC3522467  PMID: 23248388
Alcohol consumption; gender; woman’s role
4.  Universal screening for alcohol and drug use and racial disparities in Child Protective Services reporting 
This study examines racial disparities in Child Protective Services (CPS) reporting at delivery in a county with universal screening for alcohol/drug use in prenatal care. It also explores two mechanisms through which universal screening could reduce reporting disparities: Equitable Surveillance and Effective Treatment. Equitable Surveillance is premised on the assumptions that identification of drug use through screening in prenatal care leads to CPS reporting at delivery and that Black women are screened more than White women, which leads to disproportionate reporting of Black newborns. Universal screening would correct this by ensuring that prenatal providers screen and therefore also report White women to CPS, thereby reducing disparities. Effective Treatment is premised on the idea that identification of drug use through screening in prenatal care leads women to receive treatment during pregnancy, which thereby reduces CPS reporting at delivery. Universal screening would lead to prenatal providers screening more Black women and thereby to more Black women receiving treatment prenatally. The increase in treatment receipt during pregnancy would then decrease the number of Black newborns reported to CPS at delivery, thereby reducing disparities. County data were used to compare the racial/ethnic distribution of women and newborns in three points in the system (identification in prenatal care, treatment entry during pregnancy, and reporting to CPS at delivery related to maternal alcohol/drug use) and explore pathways to treatment. Despite Black women having alcohol/drug use identified by prenatal care providers at similar rates to White women and entering treatment more than expected, Black newborns were 4 times more likely than White newborns to be reported to CPS at delivery. This contradicts the premise of Effective Treatment. By default, findings were more consistent with Equitable Surveillance than Effective Treatment. Providers and policy makers should not assume that universal screening in prenatal
doi:10.1007/s11414-011-9247-x
PMCID: PMC3297420  PMID: 21681593
Screening; Pregnancy; Substance-related disorders; Disparities; Child Welfare
5.  Universal Alcohol/Drug Screening in Prenatal Care: A Strategy for Reducing Racial Disparities? Questioning the Assumptions 
Maternal and child health journal  2011;15(8):1127-1134.
Agencies and organizations promoting universal screening for alcohol and drug use in prenatal care argue that universal screening will reduce White versus Black racial disparities in reporting to Child Protective Services (CPS) at delivery. Yet, no published research has assessed the impact of universal screening on reporting disparities or explored plausible mechanisms. This review defines two potential mechanisms: Equitable Surveillance and Effective Treatment and identifies assumptions underlying each mechanism. It reviews published literature relating to each assumption. Research relating to assumptions underlying each mechanism is primarily inconclusive or contradictory. Thus, available research does not support the claim that universal screening for alcohol and drug use in prenatal care reduces racial disparities in CPS reporting at delivery. Reducing these reporting disparities requires more than universal screening.
doi:10.1007/s10995-010-0720-6
PMCID: PMC3135764  PMID: 21107668
Screening; Pregnancy; Substance-related disorders; Disparities; Child Welfare
6.  Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care 
Maternal and child health journal  2011;15(3):333-341.
Objectives
Pregnant women who use drugs are more likely to receive little or no prenatal care. This study sought to understand how drug use and factors associated with drug use influence women's prenatal care use.
Methods
20 semi-structured interviews and 2 focus groups were conducted with a racially/ethnically diverse sample of low-income women using alcohol and drugs in a California county.
Results
Women using drugs attend and avoid prenatal care for reasons not connected to their drug use: concern for the health of their baby, social support, and extrinsic barriers such as health insurance and transportation. Drug use itself is a barrier for a few women. In addition to drug use, women experience multiple simultaneous risk factors. Both the drug use and the multiple simultaneous risk factors make resolving extrinsic barriers more difficult. Women also fear the effects of drug use on their baby's health and fear being reported to Child Protective Services, each of which influence women's prenatal care use.
Conclusions
Increasing the number of pregnant women who use drugs who receive prenatal care requires systems-level rather than only individual-level changes. These changes require a paradigm shift to viewing drug use in context of the person and society and acceptance of responsibility for unintended consequences of public health bureaucratic procedures and messages about effects of drug use during pregnancy.
doi:10.1007/s10995-010-0594-7
PMCID: PMC2904854  PMID: 20232126
illicit drugs; prenatal care; pregnant women; consumer involvement
7.  Income Inequality, Alcohol Use, and Alcohol-Related Problems 
American journal of public health  2012;103(4):649-656.
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.
doi:10.2105/AJPH.2012.300882
PMCID: PMC3673268  PMID: 23237183
8.  Women’s perspectives on screening for alcohol and drug use in prenatal care 
Background
Screening for alcohol and drug use in prenatal care is widely promoted in the United States as a public health strategy for reducing alcohol and drug use during pregnancy. However, the published literature does not consider women’s perspectives or the potential negative ramifications of screening.
Methods
Twenty semi-structured interviews and two focus groups [n=38] were conducted with a racially/ethnically diverse sample of low-income pregnant and parenting women using alcohol and/or drugs in a northern California county.
Results
Most women were averse to having drug but not alcohol use identified and were mistrustful of providers’ often inconspicuous efforts to discover drug use. Women expected psychological, social, and legal consequences from being identified, including feelings of maternal failure, judgment by providers, and reports to Child Protective Services. Women did not trust providers to protect them from these consequences. Rather, they took steps to protect themselves. They avoided and emotionally disengaged from prenatal care, attempted to stop using substances that could be detected by urine tests prior to prenatal care visits, and shared strategies within social networks for getting the benefits of prenatal care while avoiding its negative consequences.
Conclusions
Considerations of the public health impact of screening for drug use in prenatal care should account for the implications of women’s physical avoidance of and emotional disengagement from prenatal care, specifically the direct effects of late, limited, and no prenatal care on pregnancy outcomes and missed opportunities for health promoting interventions.
doi:10.1016/j.whi.2010.02.003
PMCID: PMC2869475  PMID: 20457407
drug abuse screening; pregnant women; illicit drugs; consumer involvement; prenatal care
9.  What Can Alcohol Researchers Learn from Research about the Relationship Between Macro-Level Gender Equality and Violence against Women? 
Aims: This systematic review focuses on research about macro-level gender equality and violence against women (VAW) and identifies conceptually and theoretically driven hypotheses as well as lessons relevant for alcohol research. Hypotheses include: amelioration—increased equality decreases VAW; backlash—increased equality increases VAW; and convergence—increased equality reduces the gender gap; and hypotheses that distinguish between relative and absolute status, with relative status comparing men's and women's status and absolute status measuring women's status without regard to men. Methods: Systematic review of studies published through June 2009 identified through PubMed and Web of Science, as well as citing and cited articles. Results: A total of 30 studies are included. Of 85 findings examining amelioration/backlash, 25% support amelioration, 22% backlash; and 53% are null. Of 13 findings examining convergence, 31% support and 23% are inconsistent with convergence; 46% are null. Conclusion: Neither the existence nor the direction of the equality and VAW relationship can be assumed. This suggests that the relationship between macro-level gender equality and alcohol should also not be assumed, but rather investigated through research.
doi:10.1093/alcalc/agq093
PMCID: PMC3104612  PMID: 21239417
10.  Universal Alcohol/Drug Screening in Prenatal Care: A Strategy for Reducing Racial Disparities? Questioning the Assumptions 
Maternal and Child Health Journal  2010;15(8):1127-1134.
Agencies and organizations promoting universal screening for alcohol and drug use in prenatal care argue that universal screening will reduce White versus Black racial disparities in reporting to Child Protective Services (CPS) at delivery. Yet, no published research has assessed the impact of universal screening on reporting disparities or explored plausible mechanisms. This review defines two potential mechanisms: Equitable Surveillance and Effective Treatment and identifies assumptions underlying each mechanism. It reviews published literature relating to each assumption. Research relating to assumptions underlying each mechanism is primarily inconclusive or contradictory. Thus, available research does not support the claim that universal screening for alcohol and drug use in prenatal care reduces racial disparities in CPS reporting at delivery. Reducing these reporting disparities requires more than universal screening.
doi:10.1007/s10995-010-0720-6
PMCID: PMC3135764  PMID: 21107668
Screening; Pregnancy; Substance-related disorders; Disparities; Child Welfare
11.  Gender Differences in Public and Private Drinking Contexts: A Multi-Level GENACIS Analysis 
This multi-national study hypothesized that higher levels of country-level gender equality would predict smaller differences in the frequency of women’s compared to men’s drinking in public (like bars and restaurants) settings and possibly private (home or party) settings. GENACIS project survey data with drinking contexts included 22 countries in Europe (8); the Americas (7); Asia (3); Australasia (2), and Africa (2), analyzed using hierarchical linear models (individuals nested within country). Age, gender and marital status were individual predictors; country-level gender equality as well as equality in economic participation, education, and political participation, and reproductive autonomy and context of violence against women measures were country-level variables. In separate models, more reproductive autonomy, economic participation, and educational attainment and less violence against women predicted smaller differences in drinking in public settings. Once controlling for country-level economic status, only equality in economic participation predicted the size of the gender difference. Most country-level variables did not explain the gender difference in frequency of drinking in private settings. Where gender equality predicted this difference, the direction of the findings was opposite from the direction in public settings, with more equality predicting a larger gender difference, although this relationship was no longer significant after controlling for country-level economic status. Findings suggest that country-level gender equality may influence gender differences in drinking. However, the effects of gender equality on drinking may depend on the specific alcohol measure, in this case drinking context, as well as on the aspect of gender equality considered. Similar studies that use only global measures of gender equality may miss key relationships. We consider potential implications for alcohol related consequences, policy and public health.
doi:10.3390/ijerph7052136
PMCID: PMC2898041  PMID: 20623016
context of drinking; on- and off-premises alcohol use; gender equity; economic development; culture; hierarchical linear models (HLM); cross-national study; GENACIS
12.  Complex Calculations: How Drug Use During Pregnancy Becomes a Barrier to Prenatal Care 
Maternal and Child Health Journal  2010;15(3):333-341.
Pregnant women who use drugs are more likely to receive little or no prenatal care. This study sought to understand how drug use and factors associated with drug use influence women’s prenatal care use. A total of 20 semi-structured interviews and 2 focus groups were conducted with a racially/ethnically diverse sample of low-income women using alcohol and drugs in a California county. Women using drugs attend and avoid prenatal care for reasons not connected to their drug use: concern for the health of their baby, social support, and extrinsic barriers such as health insurance and transportation. Drug use itself is a barrier for a few women. In addition to drug use, women experience multiple simultaneous risk factors. Both the drug use and the multiple simultaneous risk factors make resolving extrinsic barriers more difficult. Women also fear the effects of drug use on their baby’s health and fear being reported to Child Protective Services, each of which influence women’s prenatal care use. Increasing the number of pregnant women who use drugs who receive prenatal care requires systems-level rather than only individual-level changes. These changes require a paradigm shift to viewing drug use in context of the person and society and acceptance of responsibility for unintended consequences of public health bureaucratic procedures and messages about effects of drug use during pregnancy.
doi:10.1007/s10995-010-0594-7
PMCID: PMC2904854  PMID: 20232126
Illicit drugs; Prenatal care; Pregnant women; Consumer involvement

Results 1-12 (12)