socialepi-readings-week7-oakes 2009 - improving community health for byi- final
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Community Health Interventions:
A review of research relevant to Allina Health Systems Backyard Initiative
21 December 2009
J. Michael Oakes, PhDMcKnight Presidential Fellow
Associate ProfessorDivision of Epidemiology & Community Health
Minnesota Population CenterUniversity of Minnesota
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EXECUTIVE SUMMARY`
This report summarizes scientific research relevant to Allina Health Systems
Backyard Initiative (BYI). The BYI is an effort to galvanize a coalition of community
residents and community-based, government, education and healthcare organizations
towards improving the health and healthcare of residents in Allinas backyard, defined as
persons residing within approximately one mile of Allinas corporate headquarters,
Abbott Northwestern Hospital and the Phillips Eye Institute. Motivated by the
recognition that a new model of disease prevention and healthcare is needed, Allinas
BYI represents a novel attempt to extend traditional healthcare beyond the walls of
clinics and hospitals and into a geographically bounded community.
Announced in May 2008, the BYI began with Allina engaging communitystakeholders in structured and informal conversation. Many issues and action ideas were
discussed and debated. The work resulted in the following four BYI focus
areas/interventions being identified: (1) engaging communities/building bridges, (2)
primary and secondary prevention, (3) improving care access and (4) early childhood
education.
The goal of this document is to summarize the scientific support for the focus
areas and to provide a scientific rationale for the BYI efforts. This review is centered on
peer-reviewed research papers and published summaries that address the health benefits
associated with the BYIs focus areas/intervention. Special attention is given to
experimental studies. Recall that in this context experimental studies are those in which a
health intervention is randomly assigned to persons or groups. Such studies are especially
important for community health initiatives because they help researchers disentangle the
impacts of the interventions under investigation from the background characteristics and
natural health trajectories of residents. While not without limitations, experiments may
accordingly be viewed as the relative gold standard of scientific evidence. The research
presented here was selected from works identified in electronic databases, bibliographies
of certain key papers and books, and through professional networks. Extensive effort was
devoted to identifying the most careful and neutral reviews and key summaries from the
tens of thousands of potentially relevant works. Note well that the issue of health system
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cost is not considered here. Costs are a separate and perhaps even more complicated
matter than the effects of interventions.
Engaging Community/Building Bridges
No experimental research was found that addressed the health impact of improved
community based organization activity. Related research addressing community
activation to prevent youth alcohol abuse was found to demonstrate negligible to modest
impacts. A great deal of non-experimental research on the impact of community-based
participatory efforts suggest modest health benefits are possible, but this hypothesis,
while promising, remains to be fully tested. In any event, community engagement is
probably the right thing to do.
Primary and Secondary Prevention
In terms of health (actually, disease) screening, there is mixed evidence that early
screening for certain cancers can yield preferred outcomes. Routine screening can detect
cancers of the breast, colon, rectum, cervix, prostate, oral cavity, and skin at early stages.
Yet for most of these cancers early detection has not proven to reduce mortality. What is
more, cancer remains rare for those less than 60 years of age. It follows that the overall
health benefit for a single community is muted.
Evidence of the beneficial effect of primary screening for blood pressure and
obesity is mixed. Efforts to improve community physical activity and/or diets have not
been very successful. Secondary screening after an event, such as a heart attack
suggests stronger potential beneficial impacts.
Too often overlooked, dental and oral health is important to overall health. Many
dentists and hygienists provide scaling and polishing for patients at a regular interval,
even if those patients are thought to be at low risk for developing periodontal disease.
There is debate, however, over the clinical and cost effectiveness of routine scaling and
polishing and the optimal frequency at which it should be provided. The evidence for
preventive dentistry and dental screening for youth is slightly stronger, suggesting it is
worthwhile.
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Improved Care Access
While it may be surprising, the fact is that it is difficult to estimate the health
gains associated with the provision of health insurance, especially for otherwise healthy
people. It is clear that health insurance increases the amount of health care consumed but
it is unclear the degree to which such healthcare consumption actually improves health.
Many studies document that the insured tend to have better health outcomes than the
uninsured. But the magnitude of the causal link between health insurance and better
health has not been definitively established. The reason for this is that ones insurance
coverage is determined by many of the same factors that determine health status to begin
with; that is, socioeconomic status. Absent a randomized trial wherein some needing
health insurance are provided it while insurance is withheld from others, it is difficult to
disentangle these effects. Not only are such experiments extremely expensive but thereare obvious ethical challenges too. The only randomized experiment addressing the
health effects of health insurance is the famous RAND Health Insurance experiment
conducted in the 1970s. The results from this trial showed mixed but probably beneficial
effects.
On the other hand, the provision of health care for the less healthy or already ill
seems both necessary and beneficial. Indeed, while evidence is fragmented and
incomplete, it seems clear that access to care and greater continuity of care for the
chronically ill is associated with less use of hospitals and emergency departments. And
while imperfect, there is good evidence to suggest having health insurance is healthy.
Recent attention to the impact of medical home or related changes to conventional
primary care models has yet to yield sufficient scientific data, but appears promising. End
of life care remains an important and difficult issue.
Early Childhood Education
Throughout history the best predictor of good health outcomes is ones
socioeconomic status, often measured by educational attainment. Indeed, the strong
relationship between education and health is the foundation for research into the social
determinants of health. There is virtual consensus that early life educational interventions
are necessary to mitigate the effects of disadvantage, although research addressing how
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early childhood education affects life chances is vast and complicated. Credible research
finds that for the otherwise disadvantaged, improved early learning confers value on
acquired skills, which leads to self-reinforcing motivation to learn more and early
mastery of a range of cognitive, social and emotional competencies makes learning at
later ages more efficient and therefore easier and more likely to continue. Environments
that do not stimulate the young fail to cultivate these skills and place children at an early
disadvantage. Yet as opposed to academic achievement and some employment gains,
research addressing the effects of early childhood education on health outcomes later is
life is difficult to conduct and there is scant direct evidence. Nevertheless, circumstantial
evidence suggests sustained high-quality early education confers critical advantages and
subsequent positive health effects. Again, this should not be surprising given the strong
and sustained relationship between socioeconomic status (e.g., educational attainment)and health.
Research on home visiting interventions is mixed. In terms of the BYI, an
important study evaluated the impact of a home visiting program to reduce parental risk
factors for child abuse. Unfortunately, the program did not prevent child abuse or
promote use of nonviolent discipline. It had a modest impact in preventing neglect. Home
visitors often failed to recognize parental risks and seldom linked families with
community resources. On the other hand, there is relatively good evidence that home
visiting by nurses can improve birth outcomes among the disadvantaged.
Conclusion
It is important to stress that there is no research that estimates or even considers
the combined effect the four BYI initiatives would have on a given communitys health.
This should not be surprising, the BYI is a novel comprehensive community health
improvement effort. Further, as implied above, a credible evaluation of the BYI initiative
would require enormous resources: ideally, twenty or more communities would be
randomized to the treatment or control conditions, and residents would be followed and
measured for many years to come. Difficult decisions about following persons moving
into and out of target communities would have to be made. Furthermore, decisions about
which health measure (e.g., mortality, cardiovascular health, asthma, anxiety) would be
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required. None of this is within the scope of the action-oriented BYI. Consequently,
stakeholders must look at the research that considers each of the BYI
interventions/components independently.
Overall, there is only modest direct but strong indirect scientific evidence to
support the selection and implementation of Allinas four BYI interventions. Taken
individually, the interventions might be expected to improve the short and long-term
health of certain community members. Taken together, the BYI interventions should be
expected to modestly and meaningfully improve the health of community residents,
especially those at higher risk for disease.
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TABLE OF CONTENTS
Background ......................................................................................................................... 2
I. Engaging Community/Building Bridges ......................................................................... 5
II. Primary Care and Prevention ......................................................................................... 7
III. The Provision Of Health Insurance............................................................................. 12
IV. Early Childhood Education......................................................................................... 16
V. Home visiting............................................................................................................... 20
VI. Conclusion .................................................................................................................. 22
Works Cited ...................................................................................................................... 25
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Background
It is widely known that the United States spends more on health care than another
other nation and yet it ranks relatively poorly with respect to overall measures of health
status such as longevity. Among others, Schroeder (Schroeder 2007) argues that the
paradox is explained by between-country differences in the social determinants of health,
such as tobacco policy and access to quality education, instead of the availability of high-
tech medicine. Shroeder stresses the fact that while inadequate healthcare accounts for
only approximately 10% of premature deaths it receives the lions share of attention and
resources.
It is ironic that in this age of genomics, proteomics and very high-tech medicine,
the key determinant of health remains socioeconomic status (SES), which is typically
measured by educational attainment, income and sometimes occupational prestige. As a
general rule, those of higher SES enjoy better health than those of lower SES. Social
epidemiologists have long shown this relationship to hold over place and time, and to be
graded; that is, for every increment of SES improvement health improves incrementally
too. In other words, the relationship between SES and health is not a step wherein only
those at the lowest level have inferior health, but rather a linear slope with declines along
the way. Recently, the relationship between SES and health has been appreciated by
leading medical scholars (Isaacs and Schroeder 2004; Woolf 2009). The implication isthat in order to improve health of populations, policymakers and/or interventionists must
either (a) improve healthcare for the disadvantaged and/or (b) improve the SES of the
disadvantaged (Oakes and Kaufman 2006).
The relationship between the health of individuals and the health of communities
and larger aggregates, such as states and nations, remains a central question for
researchers working on the social determinants of health. The relationship, of course, is
complicated because while individuals are affected by larger social, political and
macroeconomic forces, they also contribute to them (Macintyre, Ellaway and Cummins
2002; Oakes 2008). What is clear is that impoverished communities pose severe
structural obstacles to human development and good health (Bowles, Durlauf and Hoff
2006; Bowles, Gintis and Groves 2005; Brook et al. 1983; Goering and Feins 2003).
Further, the relationship between exposures and health over the life course is quite
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complex (Pollitt et al. 2008; Turrell et al. 2007). Questions such as What is the effect of
a parent smoking during a childs infancy on that same childs risk of lung cancer later in
life? are very difficult to answer because of intervening trends and factors. Nevertheless,
there is increasing consensus that in order to improve the health of individuals we must
improve the health the communities (i.e., their contexts) too. This means that there is
increasing consensus that the healthcare system must address the social determinants of
health at both the individual and community level.
Allina Health Systems Backyard Initiative (BYI) is an effort to galvanize a
coalition of community residents and community-based, government, education and
healthcare organizations towards improving the health and healthcare of residents in
Allinas backyard, defined as persons residing within approximately one mile of Allinas
corporate headquarters, Abbott Northwestern Hospital and the Phillips Eye Institute.Motivated by the recognition that a new model of disease prevention and healthcare is
needed, Allinas BYI represents a courageous and novel attempt to extend traditional
healthcare beyond the walls of clinics and hospitals and into the community.
Announced in May 2008, the BYI began with Allina engaging community
stakeholders in structured and informal conversation. Many issues and action ideas were
discussed and debated. This work resulted in the following four BYI focus
areas/interventions being identified: engaging communities/building bridges, primary and
secondary prevention, improving access and starting early. Notice, these interventions
aim to improve health by (1) improving healthcare access for the disadvantaged and (2)
increasing a childs SES through early educational interventions. They are also focused
simultaneously on (a) individuals and (b) the whole community.
The goal of this document is to summarize the scientific support for the focus
areas and to provide a scientific rationale for the BYI efforts. This review is centered on
peer-reviewed research papers and published summaries that address the health benefits
associated with the BYIs focus areas/intervention only. Still, it is fair to state that this
document is strikingly, if not foolishly, ambitious. There are literally thousands of
studies, papers and texts on each and every aspect of the interventions discussed here. It
is obviously impossible to know everything about each area much less summarize each
nuance. That stated, it is nevertheless important to compile the information needed into a
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single document so that both area experts and non-experts can benefit from what is
presented and, if they so chose, dig deeper by leveraging the source documents provided.
Special attention is given to experimental studies. Recall that in this context
experimental studies are those in which a health intervention is randomly assigned to
persons or groups. While not without detractors (see Imbens and Wooldridge 2009;
Nathan and Hollister Jr 2008; Sanson-Fisher et al. 2007), such studies are especially
important for community health initiatives because they help researchers disentangle the
impacts of the interventions under investigation from the background characteristics and
natural health trajectories of residents (Hannan 2006; Oakes 2004). Experiments may
accordingly be viewed as the gold standard of scientific evidence (Burtless 1995; Cook
2002).
The research presented here was selected from works identified in electronicdatabases, bibliographies of certain key papers and books, and through professional
networks. Extensive effort was devoted to identifying the most careful and neutral
reviews and key summaries from the tens of thousands of potentially relevant works. It is
worth emphasizing that the issue of health system cost is not considered here. Costs are a
separate and perhaps even more complicated matter than the effects of interventions.
It will be helpful, especially for the less familiar, to understand that the track
record social interventions aiming to improve welfare of any sort is poor. In fact, the late
sociologist and distinguished program evaluator, Peter H. Rossi, stated with regret that
after three decades of research we must appreciate the net measurable effect of any social
intervention should be expected to be nil (Rossi 1987). This Rossis Rule of program
evaluation remains true today. In other words, it has proven extremely difficult to
improve social conditions so as to improve the welfare/health of program/intervention
participants.
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reservation - researchers found little evidence of positive changes in the outcomes
targeted by the 11 intervention communities. The programs that demonstrated positive
outcomes targeted dietary behavior and adolescent substance abuse.
In a related vein, Wagenaar and colleagues (Wagenaar et al. 2000) conducted a
novel experiment in which he endeavored to activate community action in a random set
of communities so as to show the effects on youth alcohol use and abuse. Unlike many
other interventions, Wagenaars intervention aimed to directly motivate community
members to work together toward the common goal -- a collective action problem. While
not definitive or especially strong, these results hold promise for similar work to activate
community members themselves.
A related but clearly distinct approach to community improvement is called
community-based participatory research (CBPR). According to Lantz and colleagues(Lantz et al. 2006), CBPR is an approach to research that consciously blurs the line
between researchers and the researched, or makes research subjects more than mere
objects of research. CBPR is a collaborative approach to research that engages partners
from a community in all phases of the research process, with a shared goal of producing
knowledge that will be translated into action or positive social change for the community.
As Lantz and colleagues reveal, in the realm of public health, CBPR efforts often focus
on improving community health status and/or reducing social disparities in health.
Much of the published literature regarding CBPR involves examples of
intervention research in which a participatory approach was used to identify a community
need or problem, to design an intervention, programmatic or policy response, to evaluate
the intervention, and to make positive community change based on the research results
(Lantz et al. 2006). Examples of intervention research using a CBPR approach include
HIV Testing and Counseling for Latina Women in Los Angeles Seattle Partners adult
vaccine intervention, the Sierra Stanford Partnership in Northern and the Center for
Urban Epidemiological Studies policy research to promote reintegration of drug users
leaving jail in New York City (Lantz et al. 2006).
While clearly gaining popularity, a key question remains: Does CBPR work?
What is the evidence that a participatory approach to public health research is effective
and worthwhile? Since, according to Lantz and colleagues, CBPR is an approach to
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research rather than an intervention in and of itself, this is a challenging question to
attempt to answer. Some could argue that a better question is whether or not CBPR
produces research results that are more likely to meet the long-term goals of creating
interventions that address important community issues, identifying the mechanisms by
which health disparities are created and perpetuated, and enhancing community capacity
to identify and address salient issues on a long-term basis. A growing empirical literature
suggests that this is indeed the case. In a recent evidence-based review of the CBPR
literature related to health sponsored by the Agency for Healthcare Research and Quality
(Viswanathan et al. 2004), researchers found evidence of enhanced research quality in 11
of the 12 completed intervention studies reviewed. This included documented evidence
of enhanced participant recruitment in 8 studies, improved research methods in 4 studies,
improved variable measurement in 3 studies, and improved intervention outcomes in 2studies. This literature review also concluded that that there was very little evidence of
diminished research quality resulting from CBPR was reported (Viswanathan et al.
2004). An additional conclusion was that 47 of the 60 CBPR studies analyzed for the
review reported evidence of enhanced community capacity as an outcome of the CBPR
project, with 9 studies also documenting increased capacity among researchers.
It thus seems fair to state that there is value added from using a participatory
approach in health-related research. But until this belief can be experimentally (or at least
better) tested, the impact of CBPR on actual community health outcomes remains
uncertain.
II. Primary Care and Prevention
Since the advent of modern medicine, circa 1920, the public has largely
associated the observable increase in length and quality of life with physicians and
medicine. There can be no question that there is truth to this, especially when it comes
to treatment of illness and trauma care. But the evidence supporting the conclusion for
primary prevention (ie, preventing disease in the first place) is less clear.
Among others, Thomas McKeown and Robert Fogel are distinguished pillars of
skepticism when it comes to the historical role of medicine and physicians in lengthening
life (Fogel 1995; McKeown 1976; McKeown and Brown 1955). McKeown ties progress
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to the rise of public health infrastructure, such as sanitary plumbing. Taking the long
view, Fogel, an economic historian, attributes improvements to human health to advances
in nutrition and public health accomplishments not medical care. While most of this work
is focused on England and Europe more generally, McKinlay and McKinlay (McKinlay
and McKinlay 1977) contributed similar findings for America. The important work
Bunker and colleagues (Bunker, Frazier and Mosteller 1994) estimated that just 16% of
the life expectancy gain in the twentieth century was due to the beneficial results of
medical care. Furthermore, many assumed that when the British adopted national health
care in 1948 inequalities in health and life expectancy would dissipate due to better
access to medical care. Yet the publication of the so-called Black Report in 1980 showed
no such gains occurred. Socioeconomic status (or social class) still predicted health with
disturbing precision. Hundreds of more recent contemporary studies come to nearlyidentical conclusions.
Family physician
There is no dispute that physicians and the medical system more generally are
often essential to save the life of a trauma victim or for treatment of the chronically ill,
whether the illness is diabetes, asthma or other ailments. On the other hand, there is
considerable uncertainty in the impact of routine physician care on disease prevention.
Goodwin and colleagues (Goodwin et al. 2001) provide a useful overview of the
relationship between primary care and health. They write that the potential of primary
care practice settings to prevent disease and morbidity through health habit counseling,
screening for asymptomatic disease, and immunizations has been incompletely met.
These authors persuasively argue that, among other things,
1. Low rates of preventive services stem, in part, from the competing demands and
opportunities of other important primary care responsibilities.
2. Previous attempts to increase rates of preventive service delivery have often
resulted in modest improvement in the delivery rates of a limited range of
preventive services.
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3. Interventions that target a broad range of screening and health habit counseling
approaches have rarely been evaluated, raising concerns that existing
interventions may improve the rate of delivery of some services at the expense of
others.
Hsiao and Boult (Hsiao and Boult 2008) take the ideas further when they note the
commonly held belief is that health care quality affects primary care outcomes, but then
state that the evidence for this belief is fragmented and incomplete. What does appear
true is that (1) greater continuity of care is associated with less use of hospitals and
emergency departments, (2) greater continuity of care is also associated with lower health
care costs, and (3) effective communication may be associated with better health status.Saultz and Lochner (Saultz and Lochner 2005) offer a critical review of the literature
regarding the relationships between interpersonal continuity of care and the outcomes and
cost of health care. The conclude that although the available literature reflects persistent
methodologic problems, it is likely that a significant association exists between
interpersonal continuity and improved preventive care and reduced hospitalization.
Future research in this area must address more specific and measurable outcomes and
more direct costs and should seek to define and measure interpersonal continuity more
explicitly.
In sum, at this point it appears safe to say that consistent and high-quality primary
care appears to help prevent disease and minimize the effects of problems once they
occur. But research on the effects of scaling-up quality primary care for a whole
community is lacking, and thus we cannot yet argue from evidence that such an approach
is beneficial. Such conclusions must come from common sense and the weight of
available circumstantial evidence.
Cancer screening
Cancer is typically viewed as one of the most dreaded diseases of modern times.
It is estimated that nearly 1.5 million US men and women will be diagnosed with and
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It is hard to argue with the fact that in term of community prevention, water
fluoridation is king. Fluoride's benefits for teeth were discovered in the 1930s and
community water fluoridation began in 1945. CDC counts fluoridated water among its
greatest public health achievements of the 20 th century (CDC 1999).
According to Dye et al (Dye et al. 2007), although dental caries has declined
significantly among school-aged children since the early 1970s, dental caries has
remained the most prevalent chronic disease of childhood. Although significant
improvements in oral health for most Americans have been made over the past four
decades, oral health disparities remain across some population groups. Research suggests
a clear gradient between oral/dental health and socioeconomic status. In fact,
approximately 45% of impoverished 20-44 year old are have untreated caries compared
to 20% of non-poor persons in the same age group (CDC 2007). Similar ratios areobserved for all age groups.
What about the benefits of routine dental care? In their recent review of the
benefits of routine dental care, (Beirne, Worthington and Clarkson 2007) conclude that
research is inconclusive and that there is a need for well conducted trials in this area
which include a sufficient number of patients to detect a true impact of routine dental
care if any, and that are of significant duration (5 years or more).
Once again, and not surprising, evidence suggests dental care for oral trauma and
treatment for existing problems is beneficial. Seeing a dentist for a toothache is a good
idea. On the other hand, evidence for routine care in community settings, while probably
helpful, is not yet conclusive. More rigorous clinical trials are needed.
III. The Provision Of Health Insurance
Access to adequate health care vis--vis health insurance remains a central
political question of our time. The presumed deleterious effect not having adequate healthinsurance is based on two important causal factors: that (1) having health insurance is
critically important to receiving medical care and (2) that medical care has a positive
effect on health status. Evidence for both factors is vast but surprisingly inconclusive.
Furthermore, direct evidence of the impact of health insurance on a whole communitys
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health does not exist. No research addressing the provision of health insurance to a
particular community was found. Hadley (Hadley 2003a) provides a remarkably
comprehensive and careful review of the literature.
In terms of the broad impact of inadequate health insurance on health, the IOM
reviewed research and estimated the lack of health insurance (among the poor) caused an
excess 18,000 deaths per year. Further, the IOM concluded that the uninsured are much
more likely than persons with insurance to go without needed care. One nationally
representative survey cited found that uninsured people were less than half as likely as
those with insurance to receive needed care, as judged by physicians, for a serious
medical condition (IOM 2001). Those without insurance also receive fewer preventive
services and less regular care for chronic conditions than people with insurance (IOM
2001). Uninsured people with chronic diseases are less likely to receive appropriate careto manage their health conditions than are those who have health insurance. The impact is
that for the five disease conditions that the Committee examined (diabetes, cardiovascular
disease, end stage renal disease, HIV infection, and mental illness), uninsured patients
had worse clinical outcomes than insured patients (IOM 2002).
It may thus seem somewhat odd then that when Brown, Bindman, and Lurie
(Brown, Bindman and Lurie 1998) reviewed the literature published between 1966 and
1996, they found the assumption of lack of insurance yielding poor health was not be
supported by rigorous research. Why? Because while research shows that health
insurance increases amount of health care consumed it is not clear if health care
consumption actually improves health. More broadly, the fundamental problem with
studying the relationship between health insurance and health is that the insured differ
than the uninsured in many ways (SES, health status, race, education, etc.). Since
insurance coverage is determined by many of the same factors that determine health
status, it is difficult to disentangle these effects. When we ask why is an uninsured person
sick we must consider whether it is because they lack insurance or because they are poor.
Randomized experiments are needed here but due to ethical and financial reasons they
are hard to do in practice.
The only randomized experiment on this subject is the RAND Health Insurance
Experiment (Brook et al. 1983; Keeler 1985; Newhouse 1982; Newhouse 1993). The
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simple description of this study is that between 1974 and 1982, a total of 3,956 people
between the ages of 14 and 61 who were free of disability that precluded work were
randomly assigned to a set of insurance plans for three or five years. The overall results
revealed that the more people had to pay for medical care the less of it they used (adults
sharing costs of care made 1/3 fewer ambulatory visits and were hospitalized 1/3 less
often than those with free care). Importantly, the reduced service use under the cost
sharing plans had little or no adverse effect on health for the average person. On the
other hand, health among the sick poor (defined as the disadvantaged 6% of the
population) was adversely affected by lack of insurance. For those with poor vision and
for low income individuals with high blood pressure, free care brought and improvements
(vision better by 0.2 Snellen lines, diastolic blood pressure lower by 3mmHg). But free
care had no effect on major health habits associated with heart disease and Cancer(smoking, weight, cholesterol levels).
Another experiment-like study is going on in Massachusetts, which now has
(virtually) universal coverage for citizens. It is not yet clear if health is improving for the
newly insured in Massachusetts. Long (Long 2008) reports that in the first year after
implementation the proportion of uninsured dropped from 13 to 7 percent, with greatest
gains among lower income and younger adults and racial minorities. But the impact on
health has not yet been determined.
While not focused on the US population, cross national experiments are
nevertheless informative. Consider that universal health coverage in Taiwan began in
1995 and Wen (Wen, Tsai and Chung 2008) attempted to assess the role of national
health insurance in improving life expectancy and reducing health disparities there. This
study found that life expectancy improved for the lower ranked classes after
implementation of universal health insurance coverage. However, the magnitude of the
reduced disparity was small and large health disparity gaps remained. Wen concluded
that relying on health insurance alone to reduce health disparities is not realistic and other
measures will need to be taken to reduce health disparities. Canada had similar results.
Universal health coverage in Canada was rolled out in stages between 1962 and 1972.
Hanratty (Hanratty 1996) examined the effect of universal health coverage on infant
health outcomes. He found a 4% decline in the infant mortality rate when using a panel of
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counties from 1960 to 1975. When using a universal sample of live births from 1960 to
1974, the incidence of low birth weight decreased by an average 1.3% for the entire
population and by 8.9% for single parents following the introduction of Canadian
National Health Insurance.
Of course several quasi-experimental studies have been conducted that analyze a
change in policy which created some variation in health coverage. The principal
limitations of these studies are that they struggle to disentangle effects of insurance from
other factors, results often apply only to specific populations, and some of them have
small sample sizes. Studies of the termination of health insurance benefits in medically
indigent adults (Lurie et al. 1984; Lurie et al. 1986) and in a low income veterans
population (Fihn and Wicher 1988) found evidence of deterioration in health; specifically
hypertension was in poor control after termination of benefits. Other studies examine public health insurance in pregnant women, children, and the elderly. These studies
showed mixed results. Again, it is clear that health care consumption increases with
public insurance (Currie and Gruber 1996; Currie and Gruber 1997) but the evidence on
degree of improvement of health outcomes is mixed.
There are numerous (thousands, actually) of studies which rely on cross-sectional
data or longitudinal data to examine health care consumption, or the effects of health
insurance on health. Most of these studies find that having health insurance improves
health. Many of them compare health outcomes for insured and uninsured individuals.
While some of these studies do have interesting results, but as noted above there may be
many (unobservable) differences between those who are insured and those who are not.
This means that causal effects of health insurance on health can not really be evaluated
using these studies. In addition, some of these studies use health care consumption as a
measure of improved health; this is a problem because health care consumption does not
necessarily improve health. See (Hadley 2003b) for more.
In sum, there is conflicting evidence to date that health insurance improves health
in the general population but there is evidence that health insurance improves the health
of specific population subgroups. There is a surprising lack of experimental studies
examining the impact of health insurance on health in a given community. In the end, this
paper endorses Hadleys (Hadley 2003a) articulate conclusion:
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This review finds that there is a substantial body of research supporting the
hypotheses that having health insurance improves health and that better health
leads to higher labor force participation and higher income. However, none of
these studies are definitive; nor are their findings universally consistent. While allof the studies reviewed, including those whose findings are consistent with the
above hypotheses, suffer from methodological flaws of varying degrees, one
general observation emerges: there is a substantial degree of qualitative
consistency across the studies that support the underlying conceptual model of
the relationship between health insurance and health. (page 60S)
IV. Early Childhood EducationThe general rule in health research is that the higher a persons or communitys
socioeconomic status the better their/its health (Rogers, Hummer and Nam 2000).
Because educational attainment is arguably the most important component of
socioeconomic status (Oakes and Rossi 2003), it follows that the higher ones educational
attainment the better their health. Substantial research confirms this relationship. Since
education is cumulative, the roots of educational success lie in early life and early
education. The question at hand, then, is what determines educational success in early life
and what interventions improve it?
It is important to emphasize that until recently there has been little attention paid
to the effects of schooling be it pre-school or college on health outcomes. Instead,
most school-effects research has focused on the impact of this or that program on IQ
scores, graduation rates, employment opportunities and so forth. Links from early
education, especially, to health outcomes later in life are few and far between. Further,
there is virtually no literature on the effect of school segregation on health, in particular
youth risk behavior and only one article was found on school racial segregation and
school violence. An exception is Tarlov (Tarlov 2008), who stresses the importance of
the recognition that the production of child development is related to the production of
health. He argues that initiatives that provide high-quality early childhood education from
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birth to five years are likely to yield high health status both at the time of the initiative
and later in life.
There is virtual consensus that early life educational interventions are necessary to
mitigate the effects of disadvantage, although research addressing how early childhood
education affects life chances is long and complicated (Gormley Jr 2007). Heckman
(Heckman 2006) reviews evidence on the effects of early environments on child
development and achievement. He writes that early learning confers value on acquired
skills, which leads to self-reinforcing motivation to learn more and early mastery of a
range of cognitive, social and emotional competencies makes learning at later ages more
efficient and therefore easier and more likely to continue. Early family environments are
major predictors of cognitive and noncognitive abilities. Environments that do not
stimulate the young fail to cultivate these skills and place children at an earlydisadvantage. Children who fall behind may never catch up. The track record for
rehabilitation later in life, be it for criminal behavior or literacy, is remarkably poor.
Cognitive skills are important, but so too are noncognitive skills such as motivation and
perseverance. Heckman writes that Investing in disadvantaged young children is a rare
public policy initiative that promotes fairness and social justice and at the same time
promotes productivity in the economy and in society at large. Early interventions targeted
toward disadvantaged children have much higher returns than later interventions (1902).
The rigorous (i.e., experimental) evidence for the benefits of early childhood
educational interventions is relatively slim. A key reason is that ethical dilemmas abound
and effects often take years or even decades to observe. Still, several important studies
exist and merit summary review.
The Perry Preschool Program was a 2-year experimental intervention for
disadvantaged African American children initially 3-4 years of age and from low SES
families. Based in Ypsilanti, MI, the program began in 1962 and went to 1965. The
intervention was a morning program followed by accompanying afternoon visits by a
teacher to the childs home. A total of 58 young students were in this treated group (65
were in the comparison group). By age ten, IQ scores of the treated children were no
better than those children in the comparison group, yet Perry Program children had higher
achievement scores since they were more motivated to learn, presumably by the program
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itself. By age 40, the treated children has higher high-school graduation rates, higher
incomes, higher percentage of home ownership, few arrests and so forth. It is for this
reason that this program has received so much attention. Of course it is not clear whether
the school curriculum or the home visits are responsible for the gains. And several severe
methodological concerns remain unanswered (Olsen 2003).
Another high-profile effort was the Abecedarian of North Carolina, which was an
intensive center-based preschool program that also targeted disadvantaged children,
starting at age 4 months. In 1972, 112 children were randomized to the special program
or a comparison group. Children in the treatment group received childcare 6-8 hours per
day, 5 days per week. Additionally, they received nutritional supplements, social work
services and medical care. Importantly, it seems that this effort permanently increased the
IQ of children. Follow-up survey research found lower levels of smoking (39% v 55%),which is obviously very important to health outcomes (Olsen 2003).
Another program receiving attention is the Chicago Child-Parent Center (CPC)
program, which is more recent and larger in scale and less intensive (and less expensive)
that the Perry or Abecedarian programs. The CPC program provided educational and
family support to children aged 3 to 9. The program ran for 2.5 hours per day, 5 days per
week during the school year and 6 weeks during the summer. The curriculum emphasized
language and math skills. Compared to a (non-randomized) comparison group, CPC
program children had better school and labor market outcomes, they were also less likely
to be victims of child abuse or neglect or to engage in criminal activity (Olsen 2003).
While the non-experimental design of this programs evaluation is concerning, the results
remain promising.
Perhaps the best known early childhood educational intervention is Head Start,
which is a large scale program that began in 1965 as part of the War on Poverty. It was
designed to improve the poor childs opportunities and achievements in order to end the
pattern of poverty. Its seven major objectives were to (1) improve the childs physical
health, (2) help the childs social and emotional development, (3) improve the childs
mental processes, (4) establish patterns and expectations of success, (5) increase the
childs ability to relate positively to family members, (6) develop in the child and family
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a responsible attitude toward society, and (7) increase the sense of dignity and self-worth
of the child and his family. (Olsen 2003)
Research on the impacts of Head Start have shown mixed results. According to a
1997 Government Accounting Office (GAO) report, from over 600 published research
articles, only a few were credibly informative. GAO concluded that the body of research
on current Head Start is insufficient to draw conclusions about the impact of the national
program (Olsen 2003). This has now changed.
Head Start was recently evaluated through an experimental design (Puma et al.
2005). Approximately 5,000 newly entering 3- and 4-year-old children applying for Head
Start were randomly assigned to either a Head Start group that had access to Head Start
program services or to a non-Head Start group that could enroll in available community
non-Head Start services, selected by their parents. Data collection began in fall 2002 andwas continued through 2006, following children through the spring of their 1st-grade
year. Preliminary results show there were small to moderate statistically significant
positive impacts for both 3- and 4-year-old children on several measures across four of
the six cognitive constructs, including pre-reading, pre-writing, vocabulary, and parent
reports of childrens literacy skills. But no significant impacts were found for the
constructs oral comprehension and phonological awareness or early mathematics skills
for either age group. For 3-year-olds, there were small to moderate statistically significant
impacts in both constructs, higher parent reports of childrens access to health care and
reportedly better health status for children enrolled in Head Start. For children who
entered the program as 4-year-olds, there are moderate statistically significant impacts on
access to health care, but no significant impacts for health status. I
Because it considers broader and longer term outcomes, a recent study by Ludwig
and Miller (Ludwig and Miller 2007) on the impacts of Head Start merits careful
consideration. In this novel regression-discontinuity design study, researchers examined
the community benefits and impacts of Head Start interventions, which began in the early
and mid 1960s. The researchers note that Head Start is more than a daycare program; it is
a comprehensive bundle of child and family intervention components designed to give
children a true head start. Components beyond preschool include parent involvement and
counseling, nutrition education, social services, mental health services, and (physical)
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health services. Outcomes suggest that educational attainment (eg, high school graduation
and college attendance) was directly improved by Head Start. What is more, related
evidence suggests that community-level child mortality declined over the twenty years
after program initiation. The remarkable upshot is that this relatively strong study shows
that comprehensive community early childhood education not only impacts the success of
target children but the long term health of communities in which they grow.
V. Home visiting
It seems natural to assume home visitation interventions would increase the health
and welfare of target persons, families and communities. Akin to a house call by a
physician, social work and other public health nursing home visits have a long record of
use. There are some positive results in this line of inquiry, especially as regards pregnancy outcomes. Outcomes such as child abuse appear more recalcitrant.
Parker and colleagues (Parker et al. 2008) describe a study called the Community
Action Against Asthma (CAAA). This is a community-based participatory research
intervention in Detroit, MI that sought to improve childrens asthma-related health by
reducing household environmental triggers for asthma. After randomization to an
intervention or control group, 298 households with a child aged 7 to 11 with persistent
asthma symptoms participated. The intervention consisted of a planned minimum of nine
household visits over a 1-year period by community environmental specialists. The aim
was to work with the family in making environmental changes in the home to reduce the
childs exposure to multiple common asthma triggers. The intervention was effective in
increasing some of the measures of lung function, reducing the frequency of cough that
wont go away and coughing with exercise, reducing the proportion of children
requiring unscheduled medical visits and reporting inadequate use of asthma controller
medication, reducing caregiver report of depressive symptoms, reducing concentrations
of dog allergen in the dust, and increasing some behaviors related to reducing indoor
environmental triggers.
David Olds and colleagues (Kitzman et al. 2000; Olds et al. 1998; Olds et al.
2004) have conducted a series of randomized field experiments to assess the impact of
home nursing visits. Evidence of impacts on a childs anti-social behavior and a womans
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birth outcomes is mixed, as the magnitude of observed impacts were small. On the other
hand, one of their more prominent studies (Olds et al. 2004) addressed an urban,
primarily black sample and examined the effects of prenatal and infancy home visits by
nurses on mothers' fertility and economic self-sufficiency and the academic and
behavioral adjustment of their children as the children finished kindergarten. A variety of
outcomes measures were examined including women's number and timing of subsequent
pregnancies, months of employment, use of welfare, food stamps, and Medicaid,
educational achievement, behavioral problems attributable to the use of substances, rates
of marriage and cohabitation, and duration of relationships with partners and their
children's behavior problems, responses to story stems, intellectual functioning, receptive
language, and academic achievement. Results were promising. Compared to those in the
comparison group, women visited by nurses had fewer subsequent pregnancies and births(1.16 vs 1.38 pregnancies and 1.08 vs 1.28 births, respectively), longer intervals between
births of the first and second children (34.28 vs 30.23 months), longer relationships with
current partners (54.36 vs 45.00 months), and, since the previous follow-up evaluation at
4.5 years, fewer months of using welfare (7.21 vs 8.96 months) and food stamps (9.67 vs
11.50 months). Nurse-visited children were more likely to have been enrolled in formal
out-of-home care between 2 and 4.5 years of age (82.0% vs 74.9%). Children visited by
nurses demonstrated higher intellectual functioning and receptive vocabulary scores
(scores of 92.34 vs 90.24 and 84.32 vs 82.13, respectively) and fewer behavior problems
in the borderline or clinical range (1.8% vs 5.4%). On the other hand, there were no
statistically significant program effects on women's education, duration of employment,
rates of marriage, being in a partnered relationship, living with the father of the child, or
domestic violence, current partner's educational level, or behavioral problems attributable
to the use of alcohol or drugs. Overall, one must be cautious given some methodological
shortcomings. But the work of Olds and colleagues shows home visits are promising.
Similarly, Lee and colleagues (Lee et al. 2009) recently reported results of a study
that assessed the effectiveness of a prenatal home-visitation program in reducing adverse
birth outcomes among socially disadvantaged pregnant women and adolescents. Here
disadvantaged pregnant women and adolescents were randomized to either an
intervention group that received bi-weekly home-visitation services (n=236) or to a
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control group (n=265). Home visitors encouraged healthy prenatal behavior, offered
social support, and provided a linkage to medical and other community services. Services
were tailored to individual needs. The risk of delivering an LBW baby was significantly
lower for the HFNY group (5.1%) than for the control group (9.8%). The risk was further
reduced for mothers who were exposed to HFNY at a gestational age of 24 weeks
These authors conclude that a prenatal home-visitation program with focus on social
support, health education, and access to services holds promise for reducing LBW
deliveries among at-risk women and adolescents.
On the other hand, in their recent review, Howard and Brooks-Gunn (Howard and
Brooks-Gunn 2009) review evaluations of nine home-visiting programs to prevent child
abuse: the Nurse-Family Partnership, Hawaii Healthy Start, Healthy Families America,
the Comprehensive Child Development Program, Early Head Start, the Infant Health andDevelopment Program, the Early Start Program in New Zealand, a demonstration
program in Queensland, Australia, and a program for depressed mothers of infants in the
Netherlands. They examine outcomes related to parenting and child well-being, including
abuse and neglect. Howard and Brooks-Gunn conclude that, overall, researchers have
found little evidence that home-visiting programs directly prevent child abuse and
neglect. But home visits can impart positive benefits to families by way of influencing
maternal parenting practices, the quality of the childs home environment, and childrens
development. And improved parenting skills, say the authors, would likely be associated
with improved child well-being and corresponding decreases in maltreatment over time.
Howard and Brooks-Gunn also report that the programs have their greatest benefits for
low-income, first-time adolescent mothers.
VI. Conclusion
The Allina Back Yard Initiative (BYI) aims to improve the health of ageographically bounded neighborhood/community area. Extensive stakeholder
discussions led researchers and practitioners to focus improvements on four areas: (1)
engaging communities/building bridges, (2) primary and secondary prevention, (3)
improving access and (4) starting early. This report aimed to summarize the scientific
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support for these efforts. As they generally yield more defensible findings, appropriate
attention was devoted to experimental studies.
In this era of high-tech medicine, multi-million dollar research efforts, and
sophisticated social science, it is remarkable that no research on multiple simultaneous
efforts to improve a communitys health was found. Above all else, this paper
demonstrates the novelty of the BYI. Whereas nearly every other effort to improve health
(1) restricted itself to one aspect of community health, such as infant mortality, or (2) one
disease, such as diabetes, the BYI aims to improve community health in the broad sense.
No research on such a comprehensive effort to improve a given small geographic area
was found.
The principal finding of this paper is that existing scientific research does not
directly support the BYI plan to improve community health. But, there is relatively strongindirect evidence that the effort will prove successful. For example, there is evidence
that, separately, community-based collaborations, some screening and preventive
medicine, improved access to medical care, and early education improvements will
increase overall community health. In other words, the BYI is both groundbreaking and,
based on reasonable inference from existing science, likely to succeed in improving the
target areas health.
It must be mentioned that several prominent commentators argue for efforts much
like the BYI. First, Acevedo-Garcia and colleagues make a strong case that we must
move beyond merely documenting differences and deficiencies in health and begin to
addressing what can be done to improve it (Acevedo-Garcia et al. 2008).Such a what
can we actually do is refreshing and dovetails with Rossis idea of implementing
politically feasible programs that can be shown to improve lives (Rossi 1980). In a series
of commentaries, Woolf persuasively argues that prevention of disease is far superior
than treating disease and that in terms of prevention the best health policy is social policy
(Woolf 2009; Woolf 2008). Any careful read of the vast literature will force one to come
to the same conclusions. Furthermore, Lantz and colleagues clearly articulate that the
medicalization of health improvements fails to recognize social structural effects, such as
poverty, education and fundamental living conditions (Lantz, Lichtenstein and Pollack
2007). Such fundamental causes (Link and Phelan 1995) lie at the heart of modern
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social epidemiology. Finally, and quite remarkably, when Williams and colleagues
independently reviewed the literature and considered how best they might improve
community health they arrived at conclusions quite similar to this paper and the BYI
initiative (Williams et al. 2008). In the face of insufficient and ambiguous research, such
an independent validation of the BYI is reassuring.
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