Associate Professor of Public Health Policy and Management
Dr. Diana Silver's research explores the impact of variation in the implementation, adoption and repeal of state and local public health policies on health outcomes, particularly alcohol consumption, motor vehicle crashes, tobacco use, and food safety. Some of her other work has examined variation in access to publicly funded services such as clinics, after-school programs, parks and playgrounds. Her work has been funded by the National Institutes of Health, the Robert Wood Johnson Foundation, the New York City Department of Health and Mental Hygiene, and several other funders.
Dr. Silver's work has been published in a variety of prominent journals, including the American Journal of Public Health, the American Journal of Health Promotion, Public Health, Tobacco Control, Journal of Safety Research, Social Science and Medicine, the American Journal of Evaluation, PLoS One, Journal of Community Health, Journal of Immigrant and Minority Health, International Journal of Equity in Health, Globalization and Health, Youth and Society, Public Administration Review and Policy Studies Journal. She is an associate editor for the American Journal of Health Promotion, and serves on the New York City Department of Health’s Health Advisory Committee. She began her career focused on the developing policies and programs that could address the epidemics of AIDS, substance abuse and violence in New York City, in such settings as schools, workplaces, jails, and homeless shelters.
Dr. Silver teaches undergraduate and master’s level courses at the School of Global Health, and trains doctoral students. In 2015, Dr. Silver received NYU’s Distinguished Teaching Award, the university’s highest honor for teaching excellence.
BA, History, Bates College, Lewiston, MEMPH, Health Education, Hunter College, New York City, NYPhD, Public Administration, New York University, New York City, NY
Distinguished Teaching Award, New York University (2015)Steinhardt Goddard Award (2011)Annual Award for Outstanding Evaluation, American Evaluation Association (2010)Public Affairs Resident Scholar, The Rockefeller Foundation (2007)
Access to HealthcareAlcohol, Tobacco and Driving PoliciesFood Safety PoliciesImplementation and Impact of Public Health RegulationsInjury PreventionNew York Department of Health and Mental HygienePublic Health LawPublic Health Policy
24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of BrazilBandi, P., Chang, V. W., Sherman, S. E., & Silver, D.
Journal titlePreventive Medicine
Volume131Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25–69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines among females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities in female smoking widened mainly until 2003 (SII: 15.8). Conversely, among males, declines were steeper in higher-educated groups only in relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute equalities in male smoking were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities in smoking vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1979–1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.
Have Health Reforms in Brazil Reduced Inequities in Access to Cancer Screenings for Women?Mullachery, P., Macinko, J., & Silver, D.
Journal titleJournal of Ambulatory Care Management
Page(s)257-266We measured asset-based and education-based inequity in utilization of 2 cancer screening tests, Pap tests and mammograms, using nationally representative surveys conducted in 2003, 2008, and 2013. Utilization of Pap tests (ages 25-59 years) and mammograms (ages 50-69 years) increased over time. Asset-based and education-based inequities declined significantly for both screening tests, particularly among women who reported a doctor visit in the previous year. This decline coincided with increases in the coverage of primary health care in Brazil. However, barriers persisted; in 2013, college-educated women were still 2.27 times more likely to have a mammogram than those who were illiterate.
Presence of Counterfeit Marlboro Gold Packs in Licensed Retail Stores in New York City: Evidence from Test PurchasesKurti, M., He, Y., Silver, D., Giorgio, M., Von Lampe, K., MacInko, J., Ye, H., Tan, F., & Mei, V.
Journal titleNicotine and Tobacco Research
Page(s)1131-1134Background: There are no independent studies measuring the availability of premium brand counterfeit cigarettes in New York City from licensed retailers. Methods: We forensically analyzed the cigarette packaging of Marlboro Gold (n = 1021) purchased from licensed tobacco retailers in New York City, using ultraviolet irradiation and light microscopy to determine whether they were counterfeit. Results: We find that while only 0.5% (n = 5) of our sample exhibits at least one characteristic synonymous with counterfeit packaging, none of our packs can be conclusively classified as counterfeit. Conclusions: We do not find any counterfeit Marlboro Gold packs purchased at full price from licensed cigarette retailers throughout New York City. Future research using test purchases should include other venues (eg, street and online) and specifically ask for discounts to ascertain the overall presence of counterfeit cigarettes. Implications: This is the first study to independently measure the availability of counterfeit cigarette packs purchased at full price from licensed retailers in New York City. We find that none of the Marlboro Gold packs purchased from licensed cigarette retailers are counterfeit.
What a Difference a Grade Makes: Evidence from New York City's Restaurant Grading PolicyRothbart, M. W., Schwartz, A. E., Calabrese, T. D., Papper, Z., Mijanovich, T., Meltzer, R., & Silver, D.
Journal titlePublic Administration Review
Page(s)651-665Can governments use grades to induce businesses to improve their compliance with regulations? Does public disclosure of compliance with food safety regulations matter for restaurants? Ultimately, this depends on whether grades matter for the bottom line. Based on 28 months of data on more than 15,000 restaurants in New York City, this article explores the impact of public restaurant grades on economic activity and public resources using rigorous panel data methods, including fixed-effects models with controls for underlying food safety compliance. Results show that A grades reduce the probability of restaurant closure and increase revenues while increasing sales taxes remitted and decreasing fines relative to B grades. Conversely, C grades increase the probability of restaurant closure and decrease revenues while decreasing sales taxes remitted relative to B grades. These findings suggest that policy makers can incorporate public information into regulations to more strongly incentivize compliance.
What Are the Financial Implications of Public Quality Disclosure? Evidence from New York City’s Restaurant Food Safety Grading PolicyMeltzer, R., Rothbart, M. W., Schwartz, A. E., Calabrese, T., Silver, D., Mijanovich, T., & Weinstein, M.
Journal titlePublic Finance Review
Page(s)170-201Grading schemes are an increasingly common method of quality disclosure for public services. Restaurant grading makes information about food safety practices more readily available and may reduce the prevalence of foodborne illnesses. However, it may also have meaningful financial repercussions. Using fine-grained administrative data that tracks food safety compliance and sales activity for the universe of graded restaurants in New York City and its bordering counties, we assess the aggregate financial effects from restaurant grading. Results indicate that the grading policy, after an initial period of adjustment, improves restaurants’ food safety compliance and reduces fines. While the average effect on revenues for graded restaurants across the municipality is null, the graded restaurants located geographically closer to an ungraded regime experience slower growth in revenues. There is also evidence of revenue convergence across graded and ungraded restaurants in the long term.
Evaluating the relationship between binge drinking rates and a replicable measure of U.S. State alcohol policy environmentsSilver, D., Macinko, J., Giorgio, M., & Bae, J. Y.
Journal titlePloS one
Issue6Excessive alcohol consumption contributes significantly to premature mortality, injuries and morbidity, and a range of U.S. state policies have been shown to reduce these behaviors. Monitoring state alcohol policy environments is essential, but methodologically challenging given that new laws may be passed (or repealed) each year, resulting in considerable variation across states. Existing measures have not been made public or have only a single year available. We develop a new replicable measure, the state alcohol policy score, for each state and year 2004–2009, that captures the essential features of a state’s evidence-based alcohol policies. We evaluate its similarity to two existing alcohol policy measures and validate it by replicating findings from a previous study that used one of those measures to assess its relationship with several binge drinking outcomes. Estimates of the association between one-year lagged state alcohol policy scores and state binge drinking outcomes, obtained from the 2005–2010 Behavioral Risk Factor Surveillance System surveys (n = 440,951, 2010), were produced using Generalized Linear Models that controlled for state and individual-level co-variates, with fixed effects for year and region. We find a 10-percent-age point increase in the state alcohol policy score was associated with a 9% lower odds of binge drinking (aOR = 0.91, 95% CI 0.89, 0.92; N = 1,992,086), a result consistent for men, women and for most age and race subgroups. We find that gender gaps in binge drinking behaviors narrowed in states with higher state alcohol policy scores. These results were nearly identical to those found in other studies using different scores obtained with the aid of expert opinions. We conclude that the score developed here is a valid measure that can be readily updated for monitoring and evaluating the variation and impact of state alcohol policies and make available our state scores for the years of the study.
Changes in health care inequity in Brazil between 2008 and 2013Mullachery, P., Silver, D., & Macinko, J.
Journal titleInternational Journal for Equity in Health
Issue1Background: Brazil has made progress towards a more equitable distribution of health care, but gains may be threatened by economic instability resulting from the 2008 global financial crisis. This study measured predictors of health care utilization and changes in horizontal inequity between 2008 and 2013. Method: Data were from two nationally representative surveys that measured a variety of sociodemographic, health behaviors and health care indicators. We used Poisson regression models to estimate adjusted prevalence ratios and the Horizontal Equity Index (HEI) standardized by health needs to measure inequity in the utilization of doctor and dentist visits, hospitalizations and reporting of a usual source of care (USC) for those 18 and older. To estimate the HEI, we ranked the population from the poorest to the richest using a wealth index. We also decomposed the HEI into its different components and assessed changes from 2008 to 2013. Results: The population proportion with doctor and dentist visits in the past year and a USC increased between 2008 and 2013, while hospitalizations declined. In 2013, pro-rich inequity in doctor visits increased significantly while the distribution of hospitalizations shifted from pro-rich in 2008 to neutral in 2013. Dentist visits were highly pro-rich and USC was slightly pro-rich; the distribution of dentist visits and USC did not change over time. Health need was a strong predictor of health care utilization regardless of the type of coverage (public or private). Education, wealth, and private health plans were associated with the pro-rich orientation of doctor and dentist visits. Private health plans contributed to the pro-rich orientation of all outcomes, while the Family Health Strategy contributed to the pro-poor orientation of all outcomes. Conclusion: The results of this study support the claim that Brazil's population continued to see absolute gains in access to care despite recent economic crises. However, gains in equity have slowed and may even decline if investments are not maintained as the country enters deeper financial and political crises.
Compliance with minimum price and legal age for cigarette purchase laws: Evidence from NYC in advance of raising purchase age to 21Silver, D., Bae, J. Y., Jimenez, G., & Macinko, J.
Journal titleTobacco control
Page(s)289-294Background New York City (NYC) raised the minimum purchase age for cigarettes from 18 to 21 on 1 August 2014. The new law is intended to decrease current smoking rates and smoking initiation among the city’s youth. Assessment of compliance with existing cigarette sales and tax laws could aid in determining what may be needed for successful implementation of the city’s new law. Purpose To assess compliance with minimum sales price and purchase age laws in NYC, before change in law. Methods Ten trained field investigators purchased cigarettes from different types of retailers throughout all five NYC boroughs, resulting in 421 purchases. Investigators noted whether they were asked for identification and the price of their purchase. Multivariable logistic and Ordinary Least Squares regression techniques were used to assess predictors of retailer compliance with sales price and minimum purchase age laws. Results In 29% of purchases, investigators did not have to produce identification (p<0.05) to purchase cigarettes. Only 3.1% of sales were at prices lower than the minimum sales price. City borough was significantly associated with purchase without identification (p<0.001) and mean sales price (p<0.024). Vendor type (independent vs chain) was significantly related to investigators being able to purchase cigarettes without identification (p<0.001). Conclusions Variation in compliance with existing laws suggests that more active monitoring of compliance with the new minimum legal purchase age will be required in order to realise the new law’s public health potential.
Detecting causality in policy diffusion processesGrabow, C., Macinko, J., Silver, D., & Porfiri, M.
Issue8A universal question in network science entails learning about the topology of interaction from collective dynamics. Here, we address this question by examining diffusion of laws across US states. We propose two complementary techniques to unravel determinants of this diffusion process: information-theoretic union transfer entropy and event synchronization. In order to systematically investigate their performance on law activity data, we establish a new stochastic model to generate synthetic law activity data based on plausible networks of interactions. Through extensive parametric studies, we demonstrate the ability of these methods to reconstruct networks, varying in size, link density, and degree heterogeneity. Our results suggest that union transfer entropy should be preferred for slowly varying processes, which may be associated with policies attending to specific local problems that occur only rarely or with policies facing high levels of opposition. In contrast, event synchronization is effective for faster enactment rates, which may be related to policies involving Federal mandates or incentives. This study puts forward a data-driven toolbox to explain the determinants of legal activity applicable to political science, across dynamical systems, information theory, and complex networks.
Over-the-counter sales of out-of-state and counterfeit tax stamp cigarettes in New York CitySilver, D., Giorgio, M. M., Bae, J. Y., Jimenez, G., & Macinko, J.
Journal titleTobacco control
Page(s)584-586Background New York City (NYC) has strict minimum cigarette price and tax stamp laws, but evidence regarding the extent of evasion of such laws in over-thecounter sales is scarce. Methods 830 packs were purchased at licensed tobacco retailers at 92 randomly selected neighbourhoods in NYC in spring and fall 2014, following the establishment of NYC’s minimum price law. The χ2 analyses of illegal tax stamps on pack, by retailer type and data collection period, are presented. Results Over 15% of packs purchased had out-of-state (4.5%) or counterfeit tax stamps (10.6%). Purchases resulted in at least one illegal pack obtained in 70% of neighbourhoods, largely from independent stores. In 21.5% of sampled neighbourhoods, it was possible to purchase an illegal pack each collection period. Conclusions Enhanced enforcement of retail sales of cigarettes is needed to ensure the full benefit of existing tobacco control laws in NYC.
Retailer compliance with tobacco control laws in New York city before and after raising the minimum legal purchase age to 21Silver, D., Macinko, J., Giorgio, M., Bae, J. Y., & Jimenez, G.
Journal titleTobacco control
Page(s)624-627Objectives: New York City (NYC) is the first large city to increase the legal minimum age for possessing tobacco products from 18 to 21 (Tobacco 21) and establish a minimum price law to reduce smoking rates among youth. However, retailer compliance with these regulations is unknown. Methods: Youthful investigators purchased cigarettes pre and post-Tobacco 21 implementation in 92 NYC neighbourhoods. Investigators recorded whether their ID was checked, the pack’s purchase price, and observed compliance with additional regulations. Multivariable OLS and Poisson regression models assess pre and post Tobacco 21 compliance with ID checks and purchase prices, controlling for retailer type, location and compliance with other laws. Results: Retailer compliance with ID checks declined from 71% to 62% (p<0.004) between periods, and holding constant other factors, compliance with ID checks and sales at legal prices declined significantly after the laws changed. Compared to chain stores, independent retailers had significantly lower compliance rates (p<0.01). Conclusions: Several aspects of tobacco control appear to have deteriorated in NYC. Greater attention to monitoring retailer compliance with all tobacco regulations will be important for Tobacco 21 laws to be effective in reducing youth access to tobacco products.
That's not how the learning works - the paradox of Reverse Innovation: A qualitative studyHarris, M., Weisberger, E., Silver, D., Dadwal, V., & Macinko, J.
Journal titleGlobalization and Health
Issue1Background: There are significant differences in the meaning and use of the term 'Reverse Innovation' between industry circles, where the term originated, and health policy circles where the term has gained traction. It is often conflated with other popularized terms such as Frugal Innovation, Co-development and Trickle-up Innovation. Compared to its use in the industrial sector, this conceptualization of Reverse Innovation describes a more complex, fragmented process, and one with no particular institution in charge. It follows that the way in which the term 'Reverse Innovation', specifically, is understood and used in the healthcare space is worthy of examination. Methods: Between September and December 2014, we conducted eleven in-depth face-to-face or telephone interviews with key informants from innovation, health and social policy circles, experts in international comparative policy research and leaders in the Reverse Innovation space in the United States. Interviews were open-ended with guiding probes into the barriers and enablers to Reverse Innovation in the US context, specifically also informants' experience and understanding of the term Reverse Innovation. Interviews were recorded, transcribed and analyzed thematically using the process of constant comparison. Results: We describe three main themes derived from the interviews. First, 'Reverse Innovation,' the term, has marketing currency to convince policy-makers that may be wary of learning from or adopting innovations from unexpected sources, in this case Low-Income Countries. Second, the term can have the opposite effect - by connoting frugality, or innovation arising from necessity as opposed to good leadership, the proposed innovation may be associated with poor quality, undermining potential translation into other contexts. Finally, the term 'Reverse Innovation' is a paradox - it breaks down preconceptions of the directionality of knowledge and learning, whilst simultaneously reinforcing it. Conclusions: We conclude that this term means different things to different people and should be used strategically, and with some caution, depending on the audience.
Understanding policy diffusion in the U.S.: An information-theoretical approach to unveil connectivity structures in slowly evolving complex systemsAnderson, R. P., Jimenez, G., Bae, J. Y., Silver, D., Macinko, J., & Porfiri, M.
Journal titleSIAM Journal on Applied Dynamical Systems
Page(s)1384-1409Detecting and explaining the relationships among interacting components has long been a focal point of dynamical systems research. In this paper, we extend these types of data-driven analyses to the realm of public policy, whereby individual legislative entities interact to produce changes in their legal and political environments. We focus on the U.S. public health policy landscape, whose complexity determines our capacity as a society to effectively tackle pressing health issues. It has long been thought that some U.S. states innovate and enact new policies, while others mimic successful or competing states. However, the extent to which states learn from others, and the state characteristics that lead two states to influence one another, are not fully understood. Here, we propose a model-free, information-theoretical method to measure the existence and direction of influence of one state's policy or legal activity on others. Specifically, we tailor a popular notion of causality to handle the slow time scale of policy adoption dynamics and unravel relationships among states from their recent law enactment histories. The method is validated using surrogate data generated from a new stochastic model of policy activity. Through the analysis of real data in alcohol, driving safety, and impaired driving policy, we provide evidence for the role of geography, political ideology, risk factors, and demographic and economic indicators on a state's tendency to learn from others when shaping its approach to public health regulation. Our method offers a new model-free approach to uncover interactions and establish cause and effect in slowly evolving complex dynamical systems.
'They hear "Africa" and they think that there can't be any good services' - perceived context in cross-national learning: A qualitative study of the barriers to Reverse InnovationHarris, M., Weisberger, E., Silver, D., & Macinko, J.
Journal titleGlobalization and Health
Issue1Background: Country-of-origin of a product can negatively influence its rating, particularly if the product is from a low-income country. It follows that how non-traditional sources of innovation, such as low-income countries, are perceived is likely to be an important part of a diffusion process, particularly given the strong social and cognitive boundaries associated with the healthcare professions. Methods: Between September and December 2014, we conducted eleven in-depth face-to-face or telephone interviews with key informants from innovation, health and social policy circles, experts in international comparative policy research and leaders in Reverse Innovation in the United States. Interviews were open-ended with guiding probes into the barriers and enablers to Reverse Innovation in the US context, specifically also to understand whether, in their experience translating or attempting to translate innovations from low-income contexts into the US, the source of the innovation matters in the adopter context. Interviews were recorded, transcribed and analyzed thematically using the process of constant comparison. Results: Our findings show that innovations from low-income countries tend to be discounted early on because of prior assumptions about the potential for these contexts to offer solutions to healthcare problems in the US. Judgments are made about the similarity of low-income contexts with the US, even though this is based oftentimes on flimsy perceptions only. Mixing levels of analysis, local and national, leads to country-level stereotyping and missed opportunities to learn from low-income countries. Conclusions: Our research highlights that prior expectations, invoked by the Low-income country cue, are interfering with a transparent and objective learning process. There may be merit in adopting some techniques from the cognitive psychology and marketing literatures to understand better the relative importance of source in healthcare research and innovation diffusion. Counter-stereotyping techniques and decision-making tools may be useful to help decision-makers evaluate the generalizability of research findings objectively and transparently. We suggest that those interested in Reverse Innovation should reflect carefully on the value of disclosing the source of the innovation that is being proposed, if doing so is likely to invoke negative stereotypes.
Age, period, and cohort effects in motor vehicle mortality in the United States, 1980-2010: The role of sex, alcohol involvement, and position in vehicleMacinko, J., Silver, D., & Bae, J. Y.
Journal titleJournal of Safety Research
Page(s)47-57Introduction Although substantive declines in motor vehicle fatalities in 1980-2010 have been observed, declines by position in the vehicle and alcohol involvement have not been well elucidated. Method Analyses of FARS data use the Intrinsic Estimator (IE) to produce estimates of all age, period, and cohort effects simultaneously by position in the car and by alcohol involvement. Results Declines in MVC deaths by position in the car vary for men and women by age and cohort over time. Cohorts born before 1970 had higher risks than those born later. Analyses using proxy indicators of alcohol involvement found the highest risks for those aged 16-24. By period, these risks declined more rapidly than non- alcohol related traffic fatalities. Conclusion Changes in risk patterns are consistent with evidence regarding the contributions of new technologies and public policy efforts to reduce fatalities, but gains have not been shared evenly by sex or position in the car. Practical applications Greater attention is needed in reducing deaths among older drivers and pedestrians. Gender differences should be addressed in prevention efforts aimed at reducing MVCs due to alcohol involvement.
Diffusion of impaired driving laws among US statesMacinko, J., & Silver, D.
Journal titleAmerican journal of public health
Page(s)1893-1900Objectives. We examined internal and external determinants of state's adoption of impaired driving laws. Methods. Data included 7 state-level, evidence-based public health laws collected from 1980 to 2010. We used event history analyses to identify predictors of first-time law adoption and subsequent adoption between state pairs. The independent variables were internal state factors, including the political environment, legislative professionalism, government capacity, state resources, legislative history, and policy-specific risk factors. The external factors were neighboring states' history of law adoption and changes in federal law. Results. We found a strong secular trend toward an increased number of laws over time. The proportion of younger drivers and the presence of a neighboring state with similar laws were the strongest predictors of first-time law adoption. The predictors of subsequent law adoption included neighbor state adoption and previous legislative action. Alcohol laws were negatively associated with first-time adoption of impaired driving laws, suggesting substitution effects among policy choices. Conclusions. Organizations seeking to stimulate state policy changes may need to craft strategies that engage external actors, such as neighboring states, in addition to mobilizing within-state constituencies.
Patterns of alcohol consumption and related behaviors in Brazil: Evidence from the 2013 National Health Survey (PNS 2013)Macinko, J., Mullachery, P., Silver, D., Jimenez, G., & Neto, O. L. M.
Journal titlePloS one
Issue7This study uses data from a nationally representative household survey (the 2013 National Health Survey, n = 62,986) to describe patterns of alcohol consumption and related behaviors among Brazilian adults. Analyses include descriptive and multivariable Poisson regression for self-reports in the past 30 days of: drinking any alcohol, binge drinking, binge drinking 4 or more times, and driving after drinking (DD); as well as age of alcohol consumption initiation. Results show that current drinking prevalence was 26%, with an average age of initiation of 18.7 years. Binge drinking was reported by 51% of drinkers, 43% of whom reported binge drinking 4 or more times. Drinking and driving was reported by nearly one quarter of those who drive a car/motorcycle. Current drinking was more likely among males, ages 25-34, single, urban, and those with more education. Binge drinking was more likely among males, older age groups, and people who started drinking before 18. Drinking and driving was higher among males, those with more education, and rural residents. Those who binge-drink were nearly 70% more likely to report DD. All behaviors varied significantly among Brazilian states. Given their potential health consequences, the levels of injurious alcohol behaviors observed here warrant increased attention from Brazilian policymakers and civil society.
Temporal trends in motor vehicle fatalities in the United States, 1968 to 2010 - a joinpoint regression analysisBandi, P., Silver, D., Mijanovich, T., & Macinko, J.
Journal titleInjury Epidemiology
Page(s)1-11Background: In the past 40 years, a variety of factors might have impacted motor vehicle (MV) fatality trends in the US, including public health policies, engineering innovations, trauma care improvements, etc. These factors varied in their timing across states/localities, and many were targeted at particular population subgroups. In order to identify and quantify differential rates of change over time and differences in trend patterns between population subgroups, this study employed a novel analytic method to assess temporal trends in MV fatalities between 1968 and 2010, by age group and sex. Methods: Cause-specific MV fatality data from traffic injuries between 1968 and 2010, based on death certificates filed in the 50 states, and DC were obtained from Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). Long-term (1968 to 2010) and short-term (log-linear piecewise segments) trends in fatality rates were compared for males and females overall and in four separate age groups using joinpoint regression. Results: MV fatalities declined on average by 2.4% per year in males and 2.2% per year in females between 1968 and 2010, with significant declines observed in all age groups and in both sexes. In males overall and those 25 to 64 years, sharp declines between 1968 and mid-to-late 1990s were followed by a stalling until the mid-2000s, but rates in females experienced a long-term steady decline of a lesser magnitude than males during this time. Trends in those aged <1 to 14 years and 15 to 24 years were mostly steady over time, but males had a larger decline than females in the latter age group between 1968 and the mid-2000s. In ages 65+, short-term trends were similar between sexes. Conclusions: Despite significant long-term declines in MV fatalities, the application of Joinpoint Regression found that progress in young adult and middle-aged adult males stalled in recent decades and rates in males declined relatively more than in females in certain age groups. Future research is needed to establish the causes of these observed trends, including the potential role of contemporaneous MV-related policies and their repeal. Such research is needed in order to better inform the design and evaluation of future population interventions addressing MV fatalities nationally.
The effect of geography and citizen behavior on motor vehicle deaths in the United StatesAbaid, N., Macinko, J., Silver, D., & Porfiri, M.
Journal titlePloS one
Issue4Death due to motor vehicle collisions (MVCs) remains a leading cause of death in the US and alcohol plays a prominent role in a large proportion of these fatalities nationwide. Rates for these incidents vary widely among states and over time. Here, we explore the extent to which driving volume, alcohol consumption, legislation, political ideology, and geographical factors influence MVC deaths across states and time. We specify structural equation models for extracting associations between the factors and outcomes for MVC deaths and compute correlation functions of states' relative geographic and political positions to elucidate the relative contribution of these factors. We find evidence that state-level variation in MVC deaths is associated with time-varying driving volume, alcohol consumption, and legislation. These relationships are modulated by state spatial proximity, whereby neighboring states are found to share similar MVC death rates over the thirty-year observation period. These results support the hypothesis that neighboring states exhibit similar risk and protective characteristics, despite differences in political ideology.
The geometry of motor vehicle deaths in the United StatesAbaid, N., Porfiri, M., Silver, D., & Mancinko, J.
Journal titlePLoS One
Child passenger safety laws in the United States, 1978-2010: Policy diffusion in the absence of strong federal interventionBae, J. Y., Anderson, E., Silver, D., & Macinko, J.
Journal titleSocial Science and Medicine
Page(s)30-37This article examines the diffusion of U.S. state child passenger safety laws, analyzing over-time changes and inter-state differences in all identifiable features of laws that plausibly influence crash-related morbidity and mortality. The observed trend shows many states' continuing efforts to update their laws to be consistent with latest motor vehicle safety recommendations, with each state modifying their laws on average 6 times over the 30-year period. However, there has been a considerable time lag in knowledge diffusion and policy adoption. Even though empirical evidence supporting the protective effect of child restraint devices was available in the early 1970s, laws requiring their use were not adopted by all 50 states until 1986. For laws requiring minors to be seated in rear seats, the first state law adoption did not occur until two decades after the evidence became publicly available. As of 2010, only 12 states explicitly required the use of booster seats, 9 for infant seats and 6 for toddler seats. There is also great variation among states in defining the child population to be covered by the laws, the vehicle operators subject to compliance, and the penalties resulting from non-compliance. Some states cover only up to 4-year-olds while others cover children up to age 17. As of 2010, states have as many as 14 exemptions, such as those for non-residents, non-parents, commercial vehicles, large vehicles, or vehicles without seatbelts. Factors such as the complexity of the state of the science, the changing nature of guidelines (from age to height/weight-related criteria), and the absence of coordinated federal actions are potential explanations for the observed patterns. The resulting uneven policy landscape among states suggests a strong need for improved communication among state legislators, public health researchers, advocates and concerned citizen groups to promote more efficient and effective policymaking.
Fifty-state survey of child passenger safety laws in the US, 1978-2010: A public health approach to analyzing legal intrumentsBae, J., Anderson, E., Silver, D., & Macinko, J.
Journal titleSocial Science and Medicine
Utilization patterns and perceptions of playground users in New York CitySilver, D., Giorgio, M., & Mijanovich, T.
Journal titleJournal of Community Health
Page(s)363-371Playgrounds are assumed to be an important resource for physical activity. This study investigates seasonal utilization, user preferences, and perceptions of safety and upkeep of public playgrounds in New York City. A cross-sectional survey was conducted from May 2010 to January 2011 across 10 playgrounds in low/middle income neighborhoods in each of the five boroughs in New York City. A total of 1,396 adults accompanying children were surveyed. Outcomes included playground as main place of outdoor play, and perceptions of playground upkeep and safety. Covariates included socio-demographics and other characteristics of playground users. Multivariable logistic regression with playground/season fixed effects were used. Utilization varied substantially across the four seasons. Blacks had higher odds of reporting the playground as the main place of outdoor play (AOR 1.78, 95 % CI 1.13-2.80, p <.05). High income users had lower odds of reporting the playground as the main place of outdoor play (60-80,000: AOR 0.47, 95 % CI 0.29-0.76, p <.01, 80,000+: AOR 0.47, 95 % CI 0.28-0.79, p <.01). Racial differences in perceived upkeep and safety were not significant once playground/season fixed effects were included, highlighting the importance of neighborhood conditions. Women were more likely to report feeling unsafe within playgrounds (AOR 1.51, 95 % CI 1.12-2.02, p <.01). While some playground utilization is driven by individual characteristics, perceptions of public resources influences utilization and cannot be separated from neighborhood conditions. Increasing access to opportunities for physical activity for children requires new strategies beyond playground improvements.
The effects of state regulations and alcohol consumption on traffic fatalities 1980-2010Silver, D., Bae, J., Jimenez, G., Paul, M., & Mancinko, J.
Journal titlePublic Health
Variation in U.S. traffic safety policy environments and motor vehicle fatalities 1980-2010Silver, D., Macinko, J., Bae, J. Y., Jimenez, G., & Paul, M.
Journal titlePublic Health
Page(s)1117-1125Objective: To examine the impact of variation in state laws governing traffic safety on motor vehicle fatalities. Study design: Repeated cross sectional time series design. Methods: Fixed effects regression models estimate the relationship between state motor vehicle fatality rates and the strength of the state law environment for 50 states, 1980-2010. The strength of the state policy environment is measured by calculating the proportion of a set of 27 evidence-based laws in place each year. The effect of alcohol consumption on motor vehicle fatalities is estimated using a subset of alcohol laws as instrumental variables. Results: Once other risk factors are controlled in statistical models, states with stronger regulation of safer driving and driver/passenger protections had significantly lower motor vehicle fatality rates for all ages. Alcohol consumption was strongly associated with higher MVC death rates, as were state unemployment rates. Conclusions: Encouraging laggard states to adopt the full range of available laws could significantly reduce preventable traffic-related deaths in the U.S. - especially those among younger individuals. Estimating the relationship between different policy environments and health outcomes can quantify the result of policy gaps.