Child Abuse & Neglect 91 (2019) 23–30

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Child maltreatment and alcohol outlets in Spain: Does the country

T
drinking culture matters?
⁎
Miriam Marcoa, , Enrique Graciaa, Antonio López-Quílezb, Bridget Freisthlerc
a
Department of Social Psychology, University of Valencia, Avda. Blasco Ibáñez, 21, Valencia, 46010, Spain
b
Department of Statistics and Operations Research, University of Valencia, Dr. Moliner, 50, Burjassot, Valencia, 46100, Spain
c
College of Social Work, The Ohio State University, Stillman Hall, 1947 College Rd., Columbus, OH, 42310, USA

A R T IC LE I N F O ABS TRA CT

Keywords: Background: Alcohol outlet density has been linked to rates of substantiated maltreatment both
Child maltreatment cross-sectionally and over time. Most of these studies have been conducted in Anglo-Saxon
Alcohol outlet density countries, especially in the U.S., but other countries, where alcohol outlets and alcohol con-
European countries sumption may have different social meanings, are clearly underrepresented in the literature.
Neighborhoods
Objective: The aim of this study was to analyze whether alcohol outlet density is associated with
Drinking culture
Bayesian spatio-temporal modeling
neighborhood-level child maltreatment risk in a South-European city.
Participants and setting: A longitudinal study was conducted in the city of Valencia (Spain). As
spatial units, we used 552 census block groups. Family units with child maltreatment protection
measures from 2004 to 2015 were geocoded (n = 1799).
Methods: A Bayesian spatio-temporal autoregression model was conducted to model the outcome
variable.
Results: Results indicated that, once controlled for other neighborhood-level characteristics, the
influence of off-premise density and restaurant/cafe density were not relevant, while bar density
showed a negative relationship with child maltreatment risk. Spatially lagged alcohol outlet
variables were also not relevant in the model.
Conclusions: Our results suggest the importance of taking into account the cultural influences on
the relationship between alcohol outlets and child maltreatment risk. Future cross-cultural re-
search is needed for better understanding this relationship.

1. Introduction

Child maltreatment is a major social and public health problem. Every year, at least 850 children aged under 15 die from child
maltreatment in Europe (World Health Organization, 2013). In Spain, where this study was conducted, 42,628 minors were attended
by the national child protection system in 2015, a rate of 5.1 per 1000 (Observatorio de la Infancia, 2017). Furthermore, child
maltreatment has a great impact on children’s physical and mental health, and it affects to the criminal, health and social welfare
systems (Fang, Brown, Florence, & Mercy, 2012; Gilbert et al., 2009; World Health Organization, 2013).
An increasing number of studies have explored the influence of contextual factors in child maltreatment risk. Studies have shown
that neighborhood characteristics such as poverty, disorder, immigrant concentration or crime are linked to child maltreatment risk

⁎
Corresponding author.
E-mail addresses: Miriam.Marco-Francisco@uv.es (M. Marco), Enrique.Gracia@uv.es (E. Gracia), Antonio.Lopez@uv.es (A. López-Quílez),
Freisthler.19@osu.edu (B. Freisthler).

https://doi.org/10.1016/j.chiabu.2019.02.010
Received 15 July 2018; Received in revised form 10 February 2019; Accepted 19 February 2019
0145-2134/ © 2019 Elsevier Ltd. All rights reserved.
M. Marco, et al. Child Abuse & Neglect 91 (2019) 23–30

(Freisthler, Gruenewald, Ring, & LaScala, 2008; Gracia & Herrero, 2006; Gracia, López-Quílez, Marco, & Lila, 2017; Gracia, López-
Quílez, Marco, & Lila, 2018; Morris et al., 2018). From this neighborhood-level perspective, a substantial body of literature has
focused on the relationship between alcohol availability and child maltreatment, finding that neighborhoods with higher density of
alcohol outlets show higher risk of child maltreatment (Freisthler, 2004; Freisthler, Needell, & Gruenewald, 2005; Freisthler,
Gruenewald, Remer, Lery, & Needell, 2007; Morton, 2013; Morton, Simmel, & Peterson, 2014).
Specifically, alcohol outlet density, particularly of bars and off-premise outlets, is related to rates of substantiated maltreatment
both cross-sectionally and over time (Freisthler & Weiss, 2008; Freisthler, 2004; Freisthler, Midanik, & Gruenewald, 2004, 2007;
Morton, 2013; Morton et al., 2014). Higher densities of alcohol outlets have higher rates of total maltreatment in cross sectional
studies (Freisthler, 2004, 2008; Freisthler et al., 2005), and higher rates of referrals for investigations and entries into foster care in
longitudinal studies (Freisthler & Weiss, 2008; Freisthler et al., 2007). These relationships may differ by type of maltreatment, but
how they differ may vary by location of the study. Two studies have found higher rates of child neglect in areas with higher on
premise outlets (Morton et al., 2014), including bars per capita (Freisthler et al., 2004). However, for child physical abuse, Freisthler
et al. (2004) found higher rates in areas with more off-premise outlets, while Morton et al. (2014) found no relationship with off-
premise outlets and a positive relationship with on premise outlets.
At the population-level (i.e., use of child physical abuse or neglect by parents who may not be known to the child welfare system),
research found that having more bars within a half-mile of a parent’s residence is related to more frequent use of physical abuse while
more off-premise outlets within the same distance is related to greater use of corporal punishment, even after controlling for drinking
behaviors (Freisthler & Gruenewald, 2013). Density of alcohol outlets at the zip code moderated the relationship between drinking
level and use of physical abuse, such that light and heavy drinkers living in postal code areas with higher densities of off-premise
outlets were more likely to use physical abuse (Freisthler & Wolf, 2016). In addition, heavy drinkers living in postal codes with higher
proportion of on-premise outlets that were bars, also report more frequent use of physical abuse (Freisthler & Wolf, 2016). The
research suggests that the effect of alcohol outlet density is also significant when controlling for other neighborhood-level variables
such as concentrated disadvantage and residential instability (Coulton, Crampton, Irwin, Spilbury, & Korbin, 2007; Freisthler,
Merritt, & LaScala, 2006).
While most studies found a positive relationship between alcohol outlets (namely off-premise outlets and bars) and child mal-
treatment, this was not a universal finding. For example, Freisthler et al. (2007) found a negative relationship between the density of
restaurants and referrals for child welfare investigations, substantiations, and entries into foster care in a longitudinal study. Further,
density of off-premise outlets was negatively related to rates of child physical abuse. Thus, the relationship between alcohol outlet
density and child maltreatment is complicated and deserves further study.
Most of these studies have been conducted in Anglo-Saxon countries, especially in the U.S. (Freisthler et al., 2004, 2005, 2007;
Morton, 2013; Morton et al., 2014). Other countries, however, are clearly underrepresented in the literature. This gap needs to be
addressed, as there are some possible cultural effects that may be underlying the results obtained from a U.S. perspective.
Specifically, alcohol outlets and alcohol consumption may have different social meanings depending on the country. For example,
in Mediterranean countries alcohol-related establishments are usually located in neighborhoods with different socioeconomic
characteristics compared to U.S. cities. A study conducted in Spain showed that bars tend to be allocated in areas with higher
economic status (Marco, Freisthler, Gracia, López-Quílez, & Lila, 2017), which is contrary to previous studies in other countries. In
addition, in Mediterranean countries alcohol plays a more active part in social life, and is usually present in social, work, and family
meetings (Allamani, Voller, Kubicka, & Bloomfield, 2000; Mäkela et al., 2006).
Moreover, Mediterranean cities are characterized by a high number of recreational places, bars, and pubs compared to North-
American cities (BOP Consulting, 2015). Spain, for example, is considered one of the countries with more bars in the world, and some
reports suggest that there is approximately one bar per 175 inhabitants (Área de estudios y Análisis Económico de La Caixa, 2013).
Different social meanings regarding alcohol consumption may also affect the relationship between alcohol outlets and child
maltreatment. The U.S. is usually defined as a dry country (Room & Mäkela, 2000). Dry countries are characterized by low levels of
alcohol consumption, higher rates of abstainer people, and a tight control on drinking and selling (Room & Mäkela, 2000; Room &
Mitchell, 1972). Other countries, such as Mediterranean countries (France, Italy, Portugal, Greece, or Spain) show higher rates of
alcohol consumption, less abstainer people, and a lighter control of drinking and selling (Room & Mäkela, 2000; Room & Mitchell,
1972). The consumption of alcohol in these countries is more frequent during daily life, and alcohol drinking is not uncommon at
meals (Bloomfield, Stockwell, Gmel, & Rehn, 2003; Gual, 2006; Jose, O’Leary, Graña Gomez, & Foran, 2014).
Clearly, these cultural differences between the U.S. and other countries highlight the need to study whether the same results
obtained in the U.S. studies regarding the influence of alcohol outlets in child maltreatment are also observed in other countries. The
aim of this study is to analyze whether alcohol outlet density is associated with neighborhood-level child maltreatment risk in a
South-European city. We conducted an ecological study in a city of Spain, and we analyzed the relationship of alcohol outlet density
with child maltreatment once controlled for other neighborhood-level characteristics. To the best of our knowledge, no research
focusing on alcohol outlets and child maltreatment risk at the neighborhood-level in South-European countries have been conducted
so far.

2. Methods

2.1. Sample

This longitudinal study was conducted in the city of Valencia (the third largest city of Spain). Located close to the Mediterranean

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M. Marco, et al. Child Abuse & Neglect 91 (2019) 23–30

coast, Valencia has a population of 790,201 (Statistics Office, 2016). Census block groups were used as the spatial unit (i.e.,
neighborhoods). Valencia is divided in 552 census block groups, and this administrative unit is the smallest available: in 2016 the
average number of residents in census block groups was 1322, ranging from 617 to 2671.

2.2. Variables

2.2.1. Outcome variable

The number of family units with child maltreatment protection measures was used. This data refers to all official cases of sub-
stantiated child maltreatment (including physical, psychological, and sexual abuse, and neglect) referred by the Child Protection
Services in the city of Valencia from 2004 to 2015. The incidence of cases was used, that is, the cases were counted only the first year
that the Child Protection Services carry out the protection order. The number of family units with a protection measure in this period
was 1799 families. We geocoded each family address and all cases in each census block group were counted for each of the 12 years in
the study period.
This study was supervised by the Ethics and Data Protection Committees of the University of Valencia to assure confidentiality. All
data was completely anonymized, removing any identifying information about family members. In addition, the family addresses
used were aggregated at the census block group level, which avoids any identification.

2.2.2. Neighborhood-level control variables

The city’s Statistics Office provided data for each census block group and year for the following control variables. Economic status:
The average cadastral property value set by the City Hall which is used for taxing purposes. Education level: The average education
level of neighborhood residents based on the percentage of the population in each education level (1 = less than primary education,
2 = primary education, 3 = secondary education, 4 = college education). Immigrant concentration: Percentage of immigrant po-
pulation. Residential instability: Proportion of the population who had moved into or out of each census block group during the
previous year rate per 1000 inhabitants. Policing activity: Local Police provided a measure of policing activity as an indicator of public
disorder and crime levels. Based on their perceptions and experience, senior police officers assessed an index structured as a 5-item
scale ranged from 0 – very low level of interventions – to 4 – very high level of interventions, including interventions such as drug-
related crimes, public drunkenness and fights, vandalism, homeless people, and truancy. This index showed a good reliability values
(Cronbach’s alpha = .74), and adequate validity properties (Marco, Gracia, Martín-Fernández, & López-Quílez, 2017; Marco, Gracia,
& López-Quílez, 2017).

2.2.3. Alcohol outlet density

Data for alcohol outlet density were provided by the city’s Statistics Office for each census block group and year per square
kilometer. Three categories of alcohol outlets were used for this study (Marco, Freisthler et al., 2017). Off-premise outlets: Retail sale of
wines and beverages, and retail sale of food and beverages; Restaurants/cafes: Services in restaurants and coffee shops; and Bars.

2.2.4. Spatially lagged alcohol outlet density

Spatially lagged variables for the three categories of alcohol outlet density were created by weighting the sum of values of all
neighboring census block groups for each census block group i.
Table 1 shows the descriptive statistics for the outcome and the covariates.

2.3. Data analysis

A conditionally independent Poisson distribution was used to model the outcome variable. The Poisson distribution was con-
sidered appropriate for the data (distribution for positive and discrete data) because the outcome was a count (i.e., the number of
families with child maltreatment protection measures), and it is commonly used for events with low probability of occurrence. We

Table 1
Variables (mean, standard deviation, minimum and maximum values) at the census block group level.
Variable Mean (SD) Min Max

Economic status (€) 26,320 (13,046) 7943 98,560

Education level 3.15 (.33) 2.39 3.86
Policing activity 7.16 (3.99) 0 19
Residential instability (per 1000 inhabitants) 200 (65.96) 4.20 771.30
Immigrant concentration (%) 13.28 (66.92) 1.03 51.47
Off-premise density (km2) 55.04 (71.63) 0 1042.25
Restaurant/café density (km2) 55.86 (98.71) 0 2269.00
Bar density (km2) 164.5 (165.24) 0 2120.00
Spatially lagged off-premise density (km2) 49.91 (34.15) 0 446.30
Spatially lagged restaurant/cafe density (km2) 51.12 (52.43) 0 651.00
Spatially lagged bar density (km2) 150.30 (95.30) 2.36 2120.00

Abbreviations: SD standard deviation; Min minimum; Max maximum.

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M. Marco, et al. Child Abuse & Neglect 91 (2019) 23–30

counted the number of families in each census block group (i = 552) and each year (t = 12), using the following equation:
yit |ηit ∼ Po (Eit exp(ηit )), i = 1, …, 552, t = 1, …, 12

where Ei is the expected number of families with child maltreatment protection measures in proportion to the total number of
families in each census block group and area, and ηit refers to the log relative risk in census block group i and year t . The mean of
families with child maltreatment protection measures was 0.26, and the range went from 0 to 7.
Following this distribution, different spatial and spatio-temporal models were tested, in order to assess the best fit for the data.
Specifically, four models were tested: a baseline model, a simple BYM (Besag, York and Mollié) spatial model, a spatio-temporal
without temporal dependency, and an autoregressive model. Despite having a greater complexity, the autoregressive model showed
the best fit in terms of DIC (Deviance Information Criterion), and it was selected as the final model (see Gracia et al., 2017, for further
information regarding model selection criterion).
The autoregressive approach accounts for the spatio-temporal effect. This spatio-temporal model combines both autoregressive
time series and spatial modeling (Martínez-Beneito, López-Quílez, & Botella-Rocamora, 2008), where relative risks are spatially and
temporally dependent. This model is useful to identify those areas that show stable risks over time and those areas that show changes
in risk.
We also introduced the control variables in the model: economic status, education level, immigrant concentration, residential
instability, and policing activity. Finally, the model included the three categories of alcohol outlet density and the three categories of
spatially lagged alcohol outlet density to assess the effect of alcohol outlet density in the explanation of child maltreatment risk.
The model was defined in terms of log relative risk, ηij . The log relative risk for the different periods was defined as:
ηi1 = μ + Xit β + ∝1 + (1 − ρ2 )−1/2 ·(ϕi1 + θi1)

ηit = μ + Xit β + ∝t + ρ ·(ηi (t − 1) − μ − αt − 1) + ϕit + θit

where the first equation refers to the log-relative risk for the first observed year (2004), and the second equation is used for modelling
the following years. μ is the intercept, Xit represents the vector of covariates, β is the vector of regression coefficients, ∝t represents
the mean deviation of the risk in the year t, ρ is the temporal correlation between years (indicating the temporal correlation between
a particular year and the previous one), and ϕit and θit define the structured and unstructured spatial random effects, respectively.
The temporal correlation ρ indicates the extent to which the information from other years contributes to estimate the risk of a
specific year. A high value of ρ can be interpreted as an indicator of risks that are stable over the years, i.e., the spatial distribution
would show similar patterns from year to year (Martínez-Beneito et al., 2008).
A Bayesian approach was used for this study. Therefore, we assigned appropriate prior distributions for all parameters.
Specifically, β parameters were specified as vague Gaussian distributions; μ was modeled as an improper uniform distribution; the
autoregressive term ρ was modeled as a uniform over the whole space U (-1, 1);we assigned a normal distribution N (0,σ 2) for the
unstructured effects (θ and∝) and a conditional spatial autoregressive (CAR) model (Besag, York, & Mollié, 1991) for the structured
effect (ϕ ), defined as follows:

1 σϕ2
ϕi |ϕ−i ˜ N (
ni
∑j i
ϕj ,
ni
)
˜
where ni is the number of neighborhoods of the i -census block group, ϕ−i indicates the values of the ϕ vector except the component i ,
j ∼ i represents all units j that are neighbors of area i , and σϕ accounts for the standard deviation parameter. The prior distribution of
the standard deviations was specified by a uniform distribution σ∝, σϕ, σθ ˜ U (0,1) , following the structure of hierarchical Bayesian
models.
The Markov Chain Monte Carlo (MCMC) simulation techniques were used, and 100,000 iterations were generated, discarding the
first 10,000 as a burn-in period. Convergence was checked with the convergence diagnosis R̂ (Gelman, Carlin, Stern, & Rubin, 1990),
which was near to 1.0 for all parameters. For imputation purpose, we used the software R and the WinBUGS package.

3. Results

A Bayesian model was performed including the control variables (economic status, education level, residential instability, im-
migrant concentration, and policing activity), the spatial and spatio-temporal effects, and also incorporating the three categories of
alcohol outlet density and the three categories of spatially lagged alcohol outlet density. Table 2 shows the results of the Bayesian
regression model.
Results showed a high temporal correlation (ρ= . 91). This finding suggests that child maltreatment risk was stable over time,
with some areas showing a chronic high risk, while others remained at low risk over the years.
Results indicated that lower levels of economic status and education, higher immigrant concentration, and higher levels of
policing activity were related to higher child maltreatment risk. Residential instability did not show a relevant association with child
maltreatment.
Once these covariates were controlled for, the influence of off-premise density and restaurant/cafe density was not relevant (the
95% credible interval includes zero). Only bar density showed a relevant relationship with child maltreatment risk. Specifically, bar
density was related to lower risk of child maltreatment. Regarding the spatially lagged alcohol outlet variables, although they showed
a positive coefficient for the three parameters, the variables were not relevant (the 95% credible intervals include zero).

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M. Marco, et al. Child Abuse & Neglect 91 (2019) 23–30

Table 2
Results of the Bayesian autoregressive model.
Alcohol outlets model for substantiated child maltreatment

Mean SD 95% CrI

Intercept 4.2677 .4719 3.354, 5.2228

Economic statusa −.0136 .0041 −.0216, −.0056
Education level −1.4358 .1476 −1.7328, −1.1661
Policing activity .0288 .0108 .0068, .0493
Residential instability −.0002 .0006 −.0013, .0008
Immigrant concentration .0103 .0061 .0001, .0225
Off-premise density −.0007 .0005 −.0015, .0002
Restaurant/cafe density −.0004 .0004 −.0013, .0003
Bar density −.0006 .0003 −.0011, −.0001
Spatially lagged off-premise density .0011 .0011 −.0012, .0031
Spatially lagged restaurant/cafe density .0011 .0009 −.0006, .0028
Spatially lagged bar density .0001 .0005 −.0010, .0011
σθ .2229 .0451 .1370, .3165
σϕ .2452 .0533 .15231, .3523
σ∝ .0217 .0200 .0007, .0799
ρ .9064 .0290 .8435, .9549

Abbreviations: SD, standard deviation; CrI, credible interval; σθ standard deviation unstructured term; σϕ standard deviation spatially structured
term; σ∝ standard deviation temporally unstructured term.
a
This variable was included as the cadastral value divided by 1000 to solve computational problems with the prior distributions.

4. Discussion

The aim of this study was to analyze whether there is a relationship between alcohol outlet density and child maltreatment risk in
a South-European country. Previous research has shown a clear association between alcohol outlets and child maltreatment, sug-
gesting that child maltreatment rates are higher in areas with higher levels of alcohol outlet density (Freisthler, 2004; Freisthler et al.,
2005; Morton et al., 2014). However, most of these studies have been conducted in the U.S., and to the best of our knowledge, this is
the first study that has analyzed this relationship in other countries.
Our results confirmed that in Valencia, as in previous research conducted in other cities, there is a link between classical variables
of social disorganization theories at the neighborhood level (low education level and economic status, high levels of immigrant
concentration and crime) and child maltreatment risk. However, different results were found regarding alcohol outlet density
variables. Specifically, our results suggest that, unlike the U.S. studies, there is not a positive association between alcohol outlet
density and child maltreatment risk. Following previous research, we studied three types of alcohol outlet establishments: off-
premise, restaurants/cafes and bars (Freisthler, 2004; Freisthler et al., 2004; Gruenewald & Remer, 2006; Gruenewald, Freisthler,
Remer, LaScala, & Treno, 2006; Marco, Freisthler et al., 2017). Results showed that off-premise and restaurant/cafe density had no
relevance to explain child maltreatment risk once controlled for other neighborhood-level variables. Bar density showed a relevant
association, but in a negative way: areas with higher levels of bar density showed lower risk of child maltreatment.
These findings differ from previous literature in this research area. Regarding off-premise density, although Morton et al. (2014)
found a negative relationship between off-premise outlets and child physical abuse, most U.S. studies have shown that off-premise
establishments are more likely to be present in areas with higher social problems, violent crime, or child maltreatment in the
neighborhood (Freisthler et al., 2004; Furr-Holden et al., 2016; Zhu, Gorman, & Horel, 2004). The different meaning of off-premise
establishments may explain the results obtained in this study. It is important to note that, in Spain, alcohol is available in many food
and drink establishments, as a special license is not needed to sell alcohol: every establishment where food is sold (from small stores,
groceries, or petrol stations, to supermarkets and large stores), can expend alcohol.
Our results also showed that restaurant/cafe density was not associated with child maltreatment risk. The different meaning of
alcohol-related culture may be also explaining these findings. As noted before, in Spain alcohol is usually present in social situations
(Allamani et al., 2000; Mäkela et al., 2006). A previous study that analyzed the relationship between restaurant/café density and
alcohol-related police calls in Spain showed that restaurant/café density was negatively related to alcohol-related police calls (Marco,
Freisthler et al., 2017).
More surprising are the results regarding bar density. According to our study, bar density was negatively associated with child
maltreatment risk once controlled by other neighborhood-level characteristics, i.e., those areas with lower bar density are those
which show higher levels of child maltreatment risk. Freisthler et al. (2007) found a negative relationship between density of
restaurants in local and lagged areas and referrals for child welfare investigations, substantiations, and entries into foster care. For
restaurants in the U.S., this may be a wealth effect. Restaurants that serve alcohol could be located in higher income areas where
surveillance around child abuse and neglect is lower. In this case, parents who may be engaging in problematic parenting may not be
observed doing so or people may not feel comfortable reporting those parents. However, previous research did not find this negative
association for bar density. In the case of Spain, these results may be due to similar reasoning given that higher densities of bars are
located in wealthier areas (Marco, Freisthler et al., 2017). This may also be due to the characteristics of people who frequented bars in

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M. Marco, et al. Child Abuse & Neglect 91 (2019) 23–30

Valencia, and in general in Spanish cities: as going to bars is culturally seen as a social activity, and this activity is based on social
relationship and meeting space more than just on alcohol consumption, areas with a higher number of bars are more frequented by
young people, university students, and young workers, and they are located in trendy and wealthy areas.
Our results may be explained by the different culture regarding alcohol consumption in South-European countries, suggesting the
importance of taking into account the culture context before generalizing the results found in other countries: in this case, previous
results found in the U.S. context may not be generalizable to other cultures such as South-European cities. However, we did not test
directly this hypothesis, as we did not assess the drinking context in the model. Future research should explore this direction for
better understanding the influence of culture in the relationship between alcohol outlet density and child maltreatment.
It should be noted that children protection system in the U.S. and Spain may differ in regard to reporting, substantiating or
handling child maltreatment. Although there is a lack of comparative studies from appropriate methodologies, research from the U.S.
points that one in nine children (11% approximately) have a substantiated investigation, where neglect shows the higher rate (Kim,
Wildeman, Jonson-Reid, & Drake, 2017); in Spain, national reports indicate lower rates, with 0.5% of substantiated reports, mostly
based on residential or family foster care (Kosher, Montserrat, Attar-Schwartz, Casas, & Zeira, 2018; Observatorio de la Infancia,
2017). The country differences in cultural aspects such as the meaning of child abuse or the acceptability of physical punishment
could also lead to differences in rates of child maltreatment reporting (García, Serra, Zacarés, & García, 2018; Gracia & Herrero,
2008a; Rodriguez, Gracia, & Lila, 2016). Spanish surveys showed that 56.3% of adults supported a physical discipline (Gracia &
Herrero, 2008b), while 71.3% of U.S. citizens agree with the use of hard spanking (Gershoff, 2008). The relationship between these
differences and alcohol outlets influence remains unclear, and more research is needed.
This study has both strengths and limitations. Regarding the strengths, this is the first study that explores the relationship between
alcohol outlet and child maltreatment risk in a South-European country. This research provides new evidences to the study of child
maltreatment at the neighborhood-level, and points to the need to consider cultural differences in the study of the relationship
between alcohol outlets and child maltreatment. In addition, recent studies have shown the advantages of using a Bayesian per-
spective instead of a frequentist approach when analyzing spatial data. This research incorporates this perspective, and uses a high-
resolution (small-area) approach. While other studies have used larger units of analysis, such as counties or census tracts (Freisthler &
Weiss, 2008; Freisthler, Kepple, & Holmes, 2012), we used census block groups, which is the smallest spatial unit available in Spain.
Using this approach may avoid biases related to the aggregation of data and provide useful information for more localized inter-
ventions (Gracia et al., 2017; Jonker et al., 2013; Law, Quick, & Chan, 2014; Quick, Law, & Luan, 2017). Furthermore, we did not use
only spatial information, but we also incorporated temporal data. Taking into account the temporal distribution can provide more
accurate information about the neighborhood correlates of child maltreatment.
The study has also some limitations. First, it was conducted only in one South-European city. Future research from different
South-European countries is needed to provide further evidence regarding cultural differences in the link between alcohol outlets and
child maltreatment. It would be also interesting to replicate this analysis in other contexts (other than U.S. and South European
countries). In addition, previous studies from the U.S. did not use the same modeling when analyzing the link between child mal-
treatment an alcohol outlets. In order to avoid any differences in findings attributed to these different assumptions, future research
would benefit from conducting the same analysis, using the same modeling, the same neighborhood-level control variables, the same
outcome, and the same unit of analysis and replicate it in countries with different drinking cultures. Second, although we suggest that
the cultural characteristics may be explaining the relationship between alcohol outlets and child maltreatment found in some
countries and not in others, more research is needed to assess this explanation. This study was based on substantiated cases of child
maltreatment, but this phenomenon is still underreported, and a large number of possible cases do not get to child protection system,
or are significantly unsubstantiated (Thurston et al., 2017; WHO, 2013).
As an ecological study, we must be careful about assigning individual-level explanations to the findings. We would need to
conduct multi-level studies to understand how people characteristics, such as their drinking behavior in the places where they live,
affect maltreatment. Finally, parents may spend significant portions of their day outside of their residential neighborhood. Examining
only the residential neighborhood may be less relevant for individuals who have significant exposures to alcohol outlet densities
outside of where they live.
Although alcohol outlet density has been found to be positively related to child maltreatment risk in U.S cities, different asso-
ciations are found in other countries, and cross-cultural analysis are necessary to better understand this relationship from a cultural
perspective. In conclusion, this study points to the importance of analyzing cultural influences on the relationship between alcohol
outlets and child maltreatment risk.

Acknowledgements

This study was supported by the Spanish Ministry of Economy and Competitiveness [PSI2014-54561-P]. Miriam Marco was
supported by the FPU program of the Spanish Ministry of Education, Culture and Sports [FPU2013/00164].

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