Public views on determinants of health, interventions to improve health, and priorities for government. Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines. 'More research needed': plugging gaps in the evidence base on health inequalities. Tensions in public health policy: patient engagement, evidence-based public health and health inequalities Citizen Participation in Patient Prioritization Policy Decisions: An Empirical and Experimental Study on Patients' Characteristics Promoting Transparency in Social Science Research Evaluating the health effects of social interventions Welfare programs that target workforce participation may negatively affect mortality. The effects of expanded mental health benefits on treatment costs. The impact of cash transfers on social determinants of health and health inequalities in Sub-Saharan Africa: a systematic review protocol The Effects of Health Care Benefits on Health Care Use and Health: A Randomized Trial for Disability Insurance Beneficiaries Experimentation and social interventions: a forgotten but important history Impact of welfare reform on mortality: an evaluation of the Connecticut jobs first program, a randomized controlled trial. Randomised controlled trial of welfare rights advice accessed via primary health care: pilot study [ISRCTN61522618] Good intentions and received wisdom are not enough Economic evaluation of a task-shifting intervention for common mental disorders in India. Linking clinical and public health approaches to improve access to health care for socially disadvantaged mothers and children. A feasibility study.
OBJECTIVE There is increasing evidence about the importance of factors that impact health beyond health care and individual behavior , yet there is little public and policy discourse about these things in the United States . We surveyed Wisconsin adults to see what they think are the most important factors that affect health . We also examined which interventions they believe would improve health , and whether government should prioritize such interventions . METHODS A phone survey of a r and om sample of 1459 Wisconsin adults was conducted between September 2006 and February 2007 . RESULTS The Wisconsin public believes that health practice s , access to health care , and health insurance are the most important factors affecting health , and that health insurance is a high government priority . Other broader social and economic determinants of health , such as employment , social support , income , housing , and neighborhood factors are seen as less important to health . Although respondents believe that health practice s are important to health , they are less likely to suggest that government prioritize improving individual health practice s. Although the public believes the government should prioritize access to health care and health insurance , they are not as likely to support government implementing social or economic policies in order to improve health . CONCLUSION In light of research demonstrating the importance of social and economic determinants of health , and of ongoing public forums meant to raise awareness of these determinants of health , it will be important to track whether public opinion of Wisconsin adults changes over time to increase attention to the social and economic determinants of health and related policy initiatives In this paper , we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a r and omized policy experiment known as the Quality Improvement Demonstration Study . Among study participants , using a difference-in-difference regression model , we estimated a 9 - 12 and 4 - 9 percentage point reduction in the likelihood of wasting and having an infection , respectively , as measured by a common biomarker C-reactive Protein . Interestingly , these benefits were not apparent at the time of discharge ; the beneficial health effects were manifest several weeks after release from the hospital Policymakers and public health research ers have dem and ed better evidence of the effects of interventions on public health and health inequalities and have pointed to the relative absence of rigorous outcome evaluations in this area . While most of these commentators agree that health inequalities are a problem , the means of tackling them often seems to rest on poor evidential foundations . This is no longer surprising , as the problem has been well-documented and the solution probably seems clear : if there is not enough evidence , then obviously we need more ; and if the evidence is ‘ weak ’ , well , then , it just needs to be ‘ stronger ’ in future . The funding environment in the UK , at least , is supportive of the production of this new , stronger evidence , with several new funding initiatives which are aim ing to foster the production of new evaluations of public health interventions . However , it might be useful to consider further what ‘ more evidence ’ might look like ( that is , what sort of evidence is needed ) and how might it be ‘ stronger ’ than in the past and also to consider what additional challenges collecting this new evidence might bring . It is clear that evidence on the effectiveness and cost-effectiveness of public health interventions is often missing . Sometimes this is because policies are insufficiently subjected to outcome evaluation , perhaps because it is assumed that they are mostly beneficial and any positive outcomes can be taken as read . R and omized controlled trials of policies are particularly uncommon and there are a variety of real and perceived barriers to trials . This means that the public are frequently ‘ enrolled ’ in real-life policy ‘ experiments ’ without giving their explicit consent , or indeed without any real prospect of anyone learning anything substantial about the effects of those interventions . Although the experimental nature of most policies is generally unacknowledged , this is not always the This paper examines the proposition that there are considerable tensions between key strategies in health policy — namely , evidence -based approaches to population health improvement , reduction of health inequalities , and public and patient engagement — using ( 1 ) a critical analysis of the intersection of evidence -based public health , patient and public engagement , and health inequalities policies from a social constructionist perspective and ( 2 ) mathematical modelling of paternalistic and shared decision making in the management of hypertension in a r and om age and sex stratified community sample of residents of south east Northumberl and , UK . It is concluded that there may be unintended effects on population health of incongruities in major components of public health policy . Greater public and patient engagement may militate against the disease prevention goals of evidence -based policy , and may better engage sections of the population who already benefit from greater access and better health associated with social status and opportunity , serving to increase inequalities by further marginalising those already suffering from relative exclusion Health systems worldwide are grappling with the need to control costs to maintain system viability . With the combination of worsening economic conditions , an aging population and reductions in tax revenues , the pressures to make structural changes are expected to continue growing . Common cost control mechanisms , e.g. curtailment of patient access and treatment prioritization , are likely to be adversely viewed by citizens . It seems therefore wise to include them in the decision making processes that lead up to policy changes . In the context of a multilevel iterative mixed- method design a quantitative survey representative of the German population ( N = 2031 ) was conducted to probe the acceptance of priority setting in medicine and to explore the practicability of direct public involvement . Here we focus on preferences for patients ' characteristics ( medical aspects , lifestyle and socio-economic status ) as possible criteria for prioritizing medical services . A question naire with closed response options was fielded to gain insight into attitudes toward broad prioritization criteria of patient groups . Furthermore , a discrete choice experiment was used as a rigorous approach to investigate citizens ' preferences toward specific criteria level in context of other criteria . Both the question naire and the discrete choice experiment were performed with the same sample . The citizens ' own health and social situation are included as explanatory variables . Data were evaluated using corresponding analysis , contingency analysis , logistic regression and a multinomial exploded logit model . The results show that some medical criteria are highly accepted for prioritizing patients whereas socio-economic criteria are rejected Social scientists should adopt higher transparency st and ards to improve the quality and credibility of research . There is growing appreciation for the advantages of experimentation in the social sciences . Policy-relevant cl aims that in the past were backed by theoretical arguments and inconclusive correlations are now being investigated using more credible methods . Changes have been particularly pronounced in development economics , where hundreds of r and omized trials have been carried out over the last decade . When experimentation is difficult or impossible , research ers are using quasi-experimental design s. Governments and advocacy groups display a growing appetite for evidence -based policy-making . In 2005 , Mexico established an independent government agency to rigorously evaluate social programs , and in 2012 , the U.S. Office of Management and Budget advised federal agencies to present evidence from r and omized program evaluations in budget requests ( 1 , 2 ) Is no evidence better than any evidence when controlled studies are unethical ? Rigorous evidence on the health effects of social interventions is scarce1 2 despite calls for more evidence from r and omised studies .3 One reason for the lack of such experimental research on social interventions may be the perception among research ers , policymakers , and others that r and omised design s belong to the biomedical world and that their application to social interventions is both unethical and simplistic.4 Applying experimental design s to social interventions may be problematic but is not always impossible and is a desirable alternative to uncontrolled experimentation.3 However , even when r and omised design s have been used to evaluate social interventions , opportunities to incorporate health measures have often been missed.5 For example , income supplementation is thought to be a key part of reducing health inequalities,6 but rigorous evidence to support this is lacking because most r and omised controlled trials of income supplementation have not included health measures .5 Current moves to increase uptake of benefits offer new opportunities to establish the effects of income supplements on health . In attempting to design such a study , however , we found that r and omised or other controlled trials were difficult to justify ethically , and our eventual design was rejected by funders . # # # # Box 1 Attendance allowance A pilot study carried out by one of us ( RH ) showed substantial health gains  among elderly people after receipt of attendance allowance . We therefore decided to pursue a full scale study of the health effects of income supplementation . During the 1990s reforms to the US welfare system introduced new time limits on people 's eligibility to receive public assistance . These limits were developed to encourage welfare recipients to seek employment . Little is known about how such social policy programs may have affected participants ' health . We explored whether the Florida Family Transition Program r and omized trial , a welfare reform experiment , led to long-term changes in mortality among participants . The Florida program included a 24 - 36-month time limit for welfare participation , intensive job training , and placement assistance . We linked 3,224 participants from the experiment to 17 - 18 years of prospect i ve mortality follow-up data and found that participants in the program experienced a 16 percent higher mortality rate than recipients of traditional welfare . If our results are generalizable to national welfare reform efforts , they raise questions about whether the cost savings associated with welfare reform justify the additional loss of life BACKGROUND Mental health disorders represent one of the most common problems facing adults in the labor force . It is estimated that within a 12-month period nearly 30 % of the US population experiences some diagnosable mental health or addictive disorder . This study examines the impact that corporate benefit policies can have on mental health treatment costs . AIMS To measure the effects of a change in mental health benefit design on treatment expenditures for employees of a large US-based company . METHODS Data came from mental health treatment administrative cl aims and eligibility information provided by the company and a comparable set of cl aims for a r and omly selected control group for the years 1995 - 1998 . We measure the effect of a change in mental health benefits consisting of three major elements : a company-wide effort to destigmatize mental illness ; reduced cost-sharing for mental health treatment ; and the implementation of a provider network that emphasized access to non-physician mental health specialists . We use a two-part regression model within a difference in differences framework to examine outpatient , pharmaceutical , and combined outpatient and pharmaceutical expenditures between the treatment company and the control group . RESULTS We find that the program led to a statistically significant dollar 17 increase in outpatient costs ( excluding pharmaceutical costs ) per employee . Similar to outpatient care we find that the benefit change was associated with a statistically significant increase in pharmaceutical costs of about dollar 15 . DISCUSSION The results reveal that the mental health benefit expansion at the company led to a significant increase in aggregate mental health expenditures among employees . However , the aggregate increase in cost masks a number of interesting underlying trends in mental health utilization . First , conditional upon any mental health treatment , mental health costs were virtually unchanged before and after the benefit change . Conditional on any use , outpatient and pharmaceutical expenditures went in opposite directions , with outpatient expenditures falling and pharmaceutical expenditures increasing . IMPLICATION S FOR HEALTH CARE PROVISION AND USE Private sector initiatives can increase use of mental health care treatment through decreased cost-sharing , improved access to specialty providers , and destigmatization of mental disorders . IMPLICATION S FOR HEALTH CARE POLICY FORMULATION : Given that the vast majority of people in the US get their health insurance through employer-sponsored health insurance , efforts on the part of the private sector to recognize and treat serious chronic illnesses such as mental disorder in a proactive manner should be encouraged . IMPLICATION S FOR FUTURE RESEARCH While the aggregate cost of corporate initiatives to improve access to quality mental health care is frequently examined , it is also important to decompose the aggregate cost changes into effects from a change in the rate of initiation and changes in utilization conditional upon initiation Background There is increasing pressure to address the social determinants of health ( SDoH ) and health inequities through the implementation of culturally acceptable interventions particularly in Sub-Saharan Africa ( SSA ) where health outcomes are generally poor . Available evaluation research on cash transfers ( CTs ) suggests that the programs may influence the wider determinants of health in SSA ; yet , there has been no attempt to synthesize the evidence regarding their contribution to tackling the SDoH and health inequalities . To date , nearly all the review s on CTs ' impact on health have predominantly featured evidence from Latin America with limited transferability to the social , cultural , and political environments in SSA . Therefore , the aim of this study is to undertake a systematic review to assess the role of CTs in tackling the wider determinants of health and health inequalities in SSA . Methods / design A systematic review of published and unpublished literature on CTs ’ impact on health and health determinants covering the period 2000–2016 will be undertaken . Studies will be considered for inclusion if they present quantitative or qualitative data , including all relevant study design s. The SDoH conceptual framework will be used to guide the data extraction process . EPPI Review er software will be used for data management and analysis . Studies included in the review will be analyzed by narrative synthesis and /or meta- analysis as appropriate for the nature of the data retrieved . Discussion This review will provide empirical evidence on the impact of CTs on SDoH to inform CT policy , implementation , and research in SSA . The protocol follows the Preferred Reporting Items for Systematic Review and Meta- Analysis Protocol s ( PRISMA -P ) . Systematic review registration This protocol has been registered with the PROSPERO international prospect i ve register of systematic review s , reference CRD42015025015 Background : Under current law , most Social Security Disability Insurance ( SSDI ) beneficiaries are not eligible for Medicare until 29 months after the Social Security Administration determines the onset of their disability . During this waiting period , > 1 in 5 lacks health insurance . This study investigated the effects of providing health care benefits on the health , employment , and other services of uninsured beneficiaries . Methods : New SSDI beneficiaries without health insurance were r and omly assigned to receive health care benefits , health care benefits plus additional supports , or a control group . Results : Compared with a control group , those provided health care benefits  used more health care , had fewer unmet medical needs , spent less out of pocket on health care , and reported improved health . In addition , those provided the additional supports were more likely to look for work , but the supports did not affect work or SSDI benefits at this very early period . Conclusions : The results provide rigorous evidence that health care benefits can increase health care use and health outcomes . Longer-term follow-up is needed to fully assess the program ’s effects on its ultimate benefits and costs , including its long-term effects on health , employment , and benefit receipt The research design of the r and omised controlled trial is primarily associated today with medicine . It tends either to be ignored or regarded with suspicion by many in such disciplines as health promotion , public policy , social welfare , criminal justice , and education . However , all professional interventions in people 's lives are subject to essentially the same questions about acceptability and effectiveness . As the social reformers Sidney and Beatrice Webb pointed out in 1932 , there is far more experimentation going on in “ the world sociological laboratory in which we all live ” than in any other kind of laboratory , but most of this social experimentation is “ wrapped in secrecy ” and thus yields “ nothing to science.”1 # # # Summary points Many social scientists argue that r and omised controlled trials are inappropriate for evaluating social interventions , but they ignore a considerable history , mainly in the United States , of the use of r and omised controlled trials to assess different approaches to public policy and health promotion A tradition of experimental sociology was well established by the 1930s , built on the early use of controlled experiments in psychology and education From the early 1960s to early 1980s r and omised experiments were considered the optimal design for evaluating public policy interventions in the United States , and major evaluations using this design were carried out This approach became less popular as policy makers reacted negatively to evidence of “ near zero ” effects Lessons to be learnt about implementing r and omised controlled trials in real life setting s include the difficulty of assessing complex multi-level interventions and the challenge of integrating qualitative data The Webbs argued for a more “ scientific ” social policy , with social scientists being trained in experimental methods and evaluations of social interventions being carried out by independent investigators . They were apparently unaware that a strong tradition in experimental sociology had already been established , mainly in the United States . OBJECTIVES We examined whether Jobs First , a multicenter r and omized trial of a  welfare reform  program conducted in Connecticut , demonstrated increases in employment , income , and health insurance relative to traditional welfare ( Aid to Families with Dependent Children ) . We also investigated if higher earnings and employment improved mortality of the participants . METHODS We revisited the  Jobs First r and omized trial , successfully linking 4612 participant identifiers to 15 years of prospect i ve mortality follow-up data through 2010 , producing 240 deaths . The analysis was powered to detect a 20 % change in mortality hazards . RESULTS Significant employment and income benefits were realized among Jobs First recipients relative to traditional welfare recipients , particularly for the most disadvantaged groups . However , although none of these reached statistical significance , all participants in Jobs First ( overall , across centers , and all subgroups ) experienced higher mortality hazards than traditional welfare recipients . CONCLUSIONS Increases in income and employment produced by Jobs First relative to traditional welfare improved socioeconomic status but did not improve survival Background Little research has directly evaluated the impact of increasing financial or material re sources on health . One way of assessing this lies with assisting people to obtain full welfare benefit entitlements . In 2000–1 , 2.3 million pensioners were living in poverty in the UK and estimates suggest that around one million do not cl aim the financial support to which they are entitled . The effectiveness of welfare rights advice services delivered via primary health care to promote health and reduce health inequalities is unknown . Methods The main objectives of this study were to assess the feasibility and acceptability of a r and omised controlled trial of welfare rights advice in a community setting and identify appropriate health and social outcome measures in order to plan a definitive trial . This was a single blind , community-based , pilot r and omised controlled trial . 126 men and women aged 60 years and over , recruited from 4 general practice s in Newcastle upon Tyne , UK , participated . The intervention comprised a structured welfare rights assessment followed by active assistance with welfare benefit cl aims over the following 24 months . The control group received the intervention after a six month delay . A range of socio-economic , health , behavioural and psycho-social outcomes were measured . Results 126 out of 400 people invited agreed to participate and 109 were followed up at 24 months . Both the intervention and research procedures were feasible and acceptable to participants and professionals involved . 68 ( 58 % ) of all participants received a welfare benefit award  ( 31 financial , 16 non-financial and 21 both ) . Median time to receipt of benefits from initial assessment was 14 ( range 1 to 78 ) weeks and median financial award was £ 55 ( € 81 , $ 98 ) per household per week . There was little evidence of health-related differences between groups or over time , which could be due to limitations of the study design . Conclusion Modification of the study design , including selection of study participants , timing of interventions and length of follow up are recommended for a definitive trial . More appropriate health and psycho-social outcome measures relevant to the elderly population should be sought , particularly focussing on those issues highlighted in the accompanying qualitative study There is a common view among social and public health scientists that there is an evidence -based medicine ( EBM ) juggernaut , a powerful , naive , and overweening attempt to impose an inappropriately narrow and medical model of experimentation onto a complex social world . We have both frequently come across hostility among social scientists , and public health or health promotion practitioners or theorists , to attempts to apply EBM principles ( for example , systematic review s or experimental design s ) in social or public health setting s ( for example , sex education in schools , health promotion campaigns , or community development1 ) . We believe such hostility to be misplaced , and to be based on a number of misconceptions . The first misconception is that systematic review s and experimental design s have a wholly biomedical provenance . As Ann Oakley has pointed out , the use of experimental design s was well established in United States by the 1930s , and from the early 1960s to early 1980s there were many r and omised experiments for evaluating public policy interventions in United States , these being considered the optimum design . Much of the early literature on experimental design s ( including blinding ) came from the social sciences , as a response to the perceived need to be able to make valid causal inferences.2 The second misconception is that the “ real world ” is too complex , messy , OBJECTIVE To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary -care setting s in Goa , India . METHODS Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary -care facilities . Subjects were r and omly assigned to an intervention or a control arm . Eligible subjects in the intervention arm were given psycho-education , case management , interpersonal psychotherapy and /or antidepressants by lay health workers . Subjects in the control arm were treated by physicians . The use of health-care re sources , the disability of each subject and degree of psychiatric morbidity , as measured by the Revised Clinical Interview Schedule , were determined at 2 , 6 and 12 months . FINDINGS Complete data , from all three follow-ups , were collected from 1243 ( 75.4 % ) and 938 ( 81.7 % ) of the subjects enrolled in the study facilities from the public and private sectors , respectively . Within the public facilities , subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm . Time costs were also significantly lower in the intervention arm than in the control arm , whereas health system costs in the two arms were similar . Within the private facilities , however , the effectiveness and costs recorded in the two arms were similar . CONCLUSION Within public primary -care facilities in Goa , the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving OBJECTIVE To test the feasibility of combining home- and office-based interventions to improve access to health care and health outcomes of Medicaid-eligible mothers and infants . DESIGN R and omized trial in 2 counties in North Carolina ( 1 rural , 1 urban ) . Information on health and developmental outcomes was obtained by face-to-face interviews , medical chart abstract ions , hospital medical records , and state data tapes . PARTICIPANTS Ninety-three Medicaid-eligible first-time pregnant women in their third trimester and their subsequently born infants , who were followed up until they were 6 months old , and 3 pediatric practice s and 1 family practice . INTERVENTIONS Coordinated home visit and office intervention , office intervention , and usual care . Home visits by 3 public health nurses provided parental education and social support and linked families with needed community re sources . Women in the office intervention group were encouraged to seek health care for their infants from one of the primary care practice s. Participating offices received assistance with Medicaid billing , help developing a system to improve preventive care , and customized patient education material s. RESULTS Mothers reported that the nurses helped them in areas related to the content of the program . An office system for prevention was developed and implemented in all 4 practice s for study patients . Families in the intervention groups were more likely than control families to have had a prenatal visit with a pediatrician ( P = .01 , chi 2 ) , a primary care office as the regular source of sick care ( P = .02 , chi 2 ) , and less waiting time ( P = .02 , Student t test ) . They were also more likely to recall receiving patient education material s ( P = .007 , chi 2 ) . CONCLUSIONS It is feasible to link clinical and public health approaches to improve the quality and effectiveness of care for socially disadvantaged children . Such interventions should be tested in defined population
Our comprehensive review and meta- analysis of these experiments find suggestive evidence of health benefits associated with investments in early life , income support , and health insurance interventions .
Housing and neighborhood trials had no effect on the outcomes included in the meta-analyses .
A positive effect of the trial on its primary socioeconomic outcome was associated with higher odds of reporting health improvements .
Early life , income , and health insurance interventions have the potential to improve health .
Policy Points Social policies might not only improve economic well-being , but also health .
Health policy experts have therefore advocated for investments in social policies both to improve population health and potentially reduce health system costs .
Since the 1960s , a large number of social policies have been experimentally evaluated in the United States .
Some of these experiments include health outcomes , providing a unique opportunity to inform evidence -based policymaking .
CONTEXT Insurers and health care providers are investing heavily in nonmedical social interventions in an effort to improve health and potentially reduce health care costs .