title: Neighborhoods, obesity, and diabetes--a randomized social experiment. Experimentation and social interventions: a forgotten but important history Cost Effectiveness of the Earned Income Tax Credit as a Health Policy Investment. Conditional Cash Transfers And Health Of Low-Income Families In The US: Evaluating The Family Rewards Experiment. Trials and tribulations: cross-learning from the practices of epidemiologists and economists in the evaluation of public health interventions The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment Impact of welfare reform on mortality: an evaluation of the Connecticut jobs first program, a randomized controlled trial. Effects of a prekindergarten educational intervention on adult health: 37-year follow-up results of a randomized controlled trial. Welfare programs that target workforce participation may negatively affect mortality. Cost-effectiveness of supported housing for homeless persons with mental illness. Early Childhood Investments Substantially Boost Adult Health Does free care improve adults' health? Results from a randomized controlled trial. Consequences of cost-sharing for children's health. Gender and Crime Victimization Modify Neighborhood Effects on Adolescent Mental Health Moving to opportunity: an experimental study of neighborhood effects on mental health. Two years after a job loss: long-term impact of the JOBS program on reemployment and mental health. Adult outcomes as a function of an early childhood educational program: an Abecedarian Project follow-up. What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage Evaluating the health effects of social interventions Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial. Impact of Supported Housing on Clinical Outcomes: Analysis of a Randomized Trial Using Multiple Imputation Technique Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work. Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services. Impact of a preventive job search intervention on the likelihood of depression among the unemployed. The Effect of Class Size in Grades K-3 on Adult Earnings, Employment, and Disability Status: Evidence from a Multi-center Randomized Controlled Trial The effect of small class sizes on mortality through age 29 years: evidence from a multicenter randomized controlled trial. Randomized Trial of the Effects of Housing Assistance on the Health and Risk Behaviors of Homeless and Unstably Housed People Living with HIV The Effects of Health Care Benefits on Health Care Use and Health: A Randomized Trial for Disability Insurance Beneficiaries The effects of early education intervention on maternal employment, public assistance, and health insurance: the infant health and development program. Depressive symptoms in young adults: the influences of the early home environment and early educational child care. Good intentions and received wisdom are not enough Publication bias in clinical research Differential mental health effects of neighborhood relocation among youth in vulnerable families: results from a randomized trial. The Oregon experiment--effects of Medicaid on clinical outcomes. The effect of an early education program on adult health: the Carolina Abecedarian Project randomized controlled trial.
abstract: BACKGROUND The question of whether neighborhood environment contributes directly to the development of obesity and diabetes remains unresolved . The study reported on here uses data from a social experiment to assess the association of r and omly assigned variation in neighborhood conditions with  obesity and diabetes . METHODS From 1994 through 1998 , the Department of Housing and Urban Development ( HUD ) r and omly assigned 4498 women with children living in public housing in high-poverty urban census tracts ( in which ≥40 % of residents had incomes below the federal poverty threshold ) to one of three groups : 1788 were assigned to receive housing vouchers  , which were redeemable only if they moved to a low-poverty census tract ( where < 10 % of residents were poor ) , and counseling on moving ; 1312 were assigned to receive unrestricted , traditional vouchers , with no special counseling on moving ;  and 1398 were assigned to a control group that was offered neither of these opportunities . From 2008 through 2010 , as part of a long-term follow-up survey , we measured data indicating health outcomes , including height , weight , and level of glycated hemoglobin ( HbA(1c ) ) . RESULTS As part of our long-term survey , we obtained data on body-mass index ( BMI , the weight in kilograms divided by the square of the height in meters ) for 84.2 % of participants and data on glycated hemoglobin level for 71.3 % of participants . Response rates were similar across r and omized groups . The prevalences of a BMI of 35 or more , a BMI of 40 or more , and a glycated hemoglobin level of 6.5 % or more were lower in the group receiving the low-poverty vouchers than in the control group , with an absolute difference of 4.61 percentage points ( 95 % confidence interval [ CI ] , -8.54 to -0.69 ) , 3.38 percentage points ( 95 % CI , -6.39 to -0.36 ) , and 4.31 percentage points ( 95 % CI , -7.82 to -0.80 ) , respectively . The differences between the group receiving traditional vouchers and the control group were not significant . CONCLUSIONS The opportunity to move from a neighborhood with a high level of poverty to one with a lower level of poverty was associated with modest but potentially important reductions in the prevalence of extreme obesity and diabetes . The mechanisms underlying these associations remain unclear but warrant further investigation , given their potential to guide the design of community-level interventions intended to improve health . ( Funded by HUD and others . ) 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 . INTRODUCTION Lower-income Americans are suffering from declines in income , health , and longevity over time . Income and employment policies have been proposed as a potential non-medical solution to this problem . METHODS An interrupted time series analysis of state-level incremental supplements to the Earned Income Tax Credit ( EITC ) program  was performed using data from 1993 to 2010 Behavioral Risk Factor Surveillance System surveys and state-level life expectancy . The cost effectiveness of state EITC supplements was estimated using a microsimulation model , which was run in 2015 . RESULTS Supplemental EITC programs  increased health-related quality of life and longevity among the poor . The program costs about $ 7,786/ quality -adjusted life-year gained ( 95 % CI=$4,100 , $ 13,400 ) for the average recipient . This ratio increases with larger family sizes , costing roughly $ 14,261 ( 95 % CI=$8,735 , $ 19,716 ) for a family of three . CONCLUSIONS State supplements to EITC appear to be highly cost effective , but r and omized trials are needed to confirm these findings Opportunity  NYC-Family Rewards was the first conditional cash transfer , r and omized controlled trial for low-income families in the United States . From 2007 to 2010 , Family Rewards offered 2,377 New York City families cash transfers  that were conditional upon their investments in education , preventive health care , and parental employment . Their health and other outcomes were compared to those of a  control group of 2,372 families . The experiment led to a modest improvement in health insurance coverage and a large increase in the use of preventive dental care . It improved parents ' perception of their own health and levels of hope , mainly through improvements in reported financial well-being . While the program 's impacts on physical health were weaker , our study might not have captured effects on chronic disease risk that take longer to accrue . In the context of New York City 's operating social-safety-net programs , conditional cash transfers may have led to positive , albeit modest , improvements in the health of poor families Abstract The r and omized controlled trial is commonly used by both epidemiologists and economists to test the effectiveness of public health interventions . Yet we have noticed differences in practice between the two disciplines . In this article , we propose that there are some underlying differences between the disciplines in the way trials are used , how they are conducted and how results from trials are reported and disseminated . We hypothesize that evidence -based public health could be strengthened by underst and ing these differences , harvesting best- practice across the disciplines and breaking down communication barriers between economists and epidemiologists who conduct trials of public health interventions Policy Points : We take advantage of Oregon 's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care , how effectively it addresses unmet needs , and how those effects differ for those with and without a history of depression . Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50 % and untreated depression by more than 60 % . It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40 % . There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable population s. CONTEXT Exp and ing Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression , but the ways that Medicaid affects mental health care , how effectively it addresses unmet needs , and how those effects differ for those with and without a history of depression remain unclear . METHODS We take advantage of  Oregon 's Medicaid lottery  to gauge the causal effects of Medicaid coverage using a r and omized-controlled design , drawing on both primary and administrative data sources . FINDINGS Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50 % and untreated depression by more than 60 % . It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40 % . The share of respondents screening positive for depression dropped by 9.2 percentage points overall , and by 13.1 for those with preexisting depression diagnoses , with greatest relief in symptoms seen primarily in feeling down or hopeless , feeling tired , and trouble sleeping-consistent with the increase observed not just in medications targeting depression but also in those targeting sleep . CONCLUSIONS Medicaid coverage had significant effects on the diagnosis , treatment , and outcomes of a population with substantial unmet mental health needs . Coverage increased access to care , reduced the prevalence of untreated and undiagnosed depression , and substantially improved the symptoms of depression . There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable population 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 OBJECTIVES We used 37 years of follow-up data from a r and omized controlled trial to explore the linkage between an early educational intervention and adult health . METHODS We analyzed data from the High/Scope Perry Preschool Program ( PPP )  , an  early school-based intervention in which 123 children were r and omized to a prekindergarten education group or a control group . In addition to exploring the effects of the program on health behavioral risk factors and health outcomes , we examined the extent to which educational attainment , income , family environment , and health insurance access mediated the relationship between r and omization to PPP and behavioral and health outcomes . RESULTS The PPP led to improvements in educational attainment , health insurance , income , and family environment Improvements in these domains , in turn , lead to improvements in an array of behavioral risk factors and health ( P = .01 ) . However , despite these reductions in behavioral risk factors , participants did not exhibit any overall improvement in physical health outcomes by the age of 40 years . CONCLUSIONS Early education reduces health behavioral risk factors by enhancing educational attainment , health insurance coverage , income , and family environments . Further follow-up will be needed to determine the long-term health effects of PPP 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 Supported housing , integrating clinical and housing services , is a widely advocated intervention for homeless people with mental illness . In 1992 , the US Department of Housing and Urban Development ( HUD ) and the US Department of Veterans Affairs ( VA ) established the HUD-VA Supported Housing ( HUD-VASH ) program . METHODS Homeless veterans with psychiatric and /or substance abuse disorders or both ( N = 460 ) were r and omly assigned to 1 of 3 groups : ( 1 ) HUD-VASH , with Section 8 vouchers ( rent subsidies ) and intensive case management ( n = 182 ) ; ( 2 ) case management only , without special access to Section 8 vouchers ( n = 90 ) ; and ( 3 )  st and ard VA care  ( n = 188 ) Primary outcomes were days housed and days homeless . Secondary outcomes were mental health status , community adjustment , and costs from 4 perspectives . RESULTS During a 3-year follow-up , HUD-VASH veterans had 16 % more days housed than the case management-only group and 25 % more days housed than the st and ard care group ( P<.001 for both ) . The case management-only group had only 7 % more days housed than the st and ard care group ( P = .29 ) . The HUD-VASH group also experienced 35 % and 36 % fewer days homeless than each of the control groups ( P<.005 for both ) . There were no significant differences on any measures of psychiatric or substance abuse status or community adjustment , although HUD-VASH clients had larger social networks . From the societal perspective , HUD-VASH was 6200 US dollars ( 15 % ) more costly than st and ard care . Incremental cost-effectiveness ratios suggest that HUD-VASH cost 45 US dollars more than st and ard care for each additional day housed ( 95 % confidence interval , -19 US dollars to 108 US dollars ) . CONCLUSIONS Supported housing for homeless people with mental illness results in superior housing outcomes than intensive case management alone or st and ard care and modestly increases societal costs Look After the Child Investing in children has been demonstrated to improve their lives , both during the school-age years and afterward , as assessed by outcomes such as employment and income ; furthermore , these investments often help those in the most need . Campbell et al. ( p. 1478 ) report that these investments can also lead to improved adult health . Results from a r and omized and intensive intervention that involved 122 children in four cohorts recruited in the 1970s suggest that full-day child care for the first 5 years of life has produced adults in their 30s with better metabolic and cardiovascular health measures . Large investments in preschool children ’s education , health care , and nutrition provide long-term health benefits . High- quality early childhood programs have been shown to have substantial benefits in reducing crime , raising earnings , and promoting education . Much less is known about their benefits for adult health . We report on the long-term health effects of one of the oldest and most heavily cited early childhood interventions with long-term follow-up evaluated by the method of r and omization : the Carolina Abecedarian Project ( ABC ) . Using recently collected biomedical data , we find that disadvantaged children r and omly assigned to treatment have significantly lower prevalence of risk factors for cardiovascular and metabolic diseases in their mid-30s . The evidence is especially strong for males . The mean systolic blood pressure among the control males is 143 millimeters of mercury ( mm Hg ) , whereas it is only 126 mm Hg among the treated . One in four males in the control group is affected by metabolic syndrome , whereas none in the treatment group are affected . To reach these conclusions , we address several statistical challenges . We use exact permutation tests to account for small sample sizes and conduct a parallel bootstrap confidence interval analysis to confirm the permutation analysis . We adjust inference to account for the multiple hypotheses tested and for nonr and om attrition . Our evidence shows the potential of early life interventions for preventing disease and promoting health Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost ? In an effort to answer this question , we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been r and omly assigned to a set of insurance plans for three or five years . One plan provided free care ; the others required enrollees to pay a share of their medical bills . As previously reported , patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often . For persons with poor vision and for low-income persons with high blood pressure , free care brought an improvement ( vision better by 0.2 Snellen lines , diastolic blood pressure lower by 3 mm Hg ) ; better control of blood pressure reduced the calculated risk of early death among those at high risk . For the average participant , as well as for subgroups differing in income and initial health status , no significant effects were detected on eight other measures of health status and health habits . Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence , favorable or adverse , of free care for the average participant . For some measures of health in subgroups of the population , however , the broader confidence intervals make this conclusion less certain Do children whose families bear a percentage of their health care costs reduce their use of ambulatory care compared with those families who receive free care ? If so , does the reduction affect their health ? To answer these questions , 1,844 children aged 0 to 13 years were r and omly assigned ( for a period of 3 or 5 years ) to one of 14 insurance plans . The plans differed in the percentage of their medical bills that families paid . One plan provided free care . The others required up to 95 % coinsurance subject to a + 1,000 maximum . Children whose families paid a percentage of costs reduced use by up to one third . For the typical child in the study , this reduction caused no significant difference in either parental perceptions of their child 's health or in physiologic measures of health . Confidence intervals are sufficiently narrow for most measures to rule out the possibility that large true differences went undetected . Nor were statistically significant differences observed for children at risk of disease . Wider confidence intervals for these comparisons , however , mean that clinical ly meaningful differences , if present , could have been undetected in certain subgroups OBJECTIVE : Leverage an experimental study to determine whether gender or recent crime victimization modify the mental health effects of moving to low-poverty neighborhoods . METHODS : The  Moving to Opportunity ( MTO ) study r and omized low-income families in public housing to an intervention arm receiving vouchers to subsidize rental housing in lower-poverty neighborhoods or to controls receiving no voucher . We examined 3 outcomes 4 to 7 years after r and omization , among youth aged 5 to 16 years at baseline ( n = 2829 ) :  lifetime major depressive disorder ( MDD ) , psychological distress ( K6 ) , and Behavior Problems Index ( BPI ) . Treatment effect modification by gender and family ’s baseline report of recent violent crime victimization was tested via interactions in covariate-adjusted intent-to-treat and instrumental variable adherence-adjusted regression models . RESULTS : Gender and crime victimization significantly modified treatment effects on distress and BPI ( P < .10 ) . Female adolescents in families without crime victimization benefited from MTO treatment , for all outcomes ( Distress B = –0.19 , P = .008 ; BPI B = –0.13 , P = .06 ; MDD B = –0.036 , P = .03 ) . Male adolescents in intervention families experiencing crime victimization  had worse distress ( B = 0.24 , P = .004 ) , more behavior problems ( B = 0.30 , P < .001 ) , and nonsignificantly higher MDD ( B = 0.022 , P = .16 ) versus controls . Other subgroups experienced no effect of MTO treatment . Instrumental variable estimates were similar but larger . CONCLUSIONS : Girls from families experiencing recent violent crime victimization were significantly less likely to achieve mental health benefits , and boys were harmed , by MTO , suggesting need for cross-sectoral program supports to offset multiple stressors OBJECTIVES The health consequences of neighborhood poverty are a public health problem . Data were obtained to examine links between neighborhood residence and mental health outcomes . METHODS Moving to Opportunity was a r and omized , controlled trial in which families from public housing in high-poverty neighborhoods  were moved into private housing in near-poor or nonpoor neighborhoods , with a subset remaining in public housing . At the 3-year follow-up of the New York site , 550 families were reinterviewed . RESULTS Parents who moved to low-poverty neighborhoods  reported significantly less distress than parents who remained in high-poverty neighborhoods . Boys who moved to less poor neighborhoods reported significantly fewer anxious/depressive and dependency problems than did boys who stayed in public housing . CONCLUSIONS This study provides experimental evidence of neighborhood income effects on mental health Analyses of data from a r and omized field experiment with 1,801 participants ( A.D. Vinokur , R.H. Price . & Y.Schul , 1995 ) examined the long-term effects of a job- search workshop ( JOBS )  and the independent effects of demographic and psychological factors on reemployment and mental health outcomes . Two years after the JOBS workshop , the experimental group had significantly higher levels of reemployment and monthly income , lower levels of depressive symptoms , lower likelihood of experiencing a major depressive episode in the last year , and better role and emotional functioning compared with the control group .  Baseline job- search motivation and sense of mastery had both direct and interactive effects ( with experimental condition ) on reemployment and mental health outcomes , respectively . The interactive effects demonstrated larger benefits for those who had initial low levels of job- search motivation and mastery Adult ( age 30 )  educational , economic , and social-emotional adjustment outcomes were investigated for participants in the Abecedarian Project , a r and omized controlled trial of  early childhood education for children from low-income families . Of the original 111 infants enrolled ( 98 % African American ) , 101 took part in the age 30 follow-up . Primary indicators of educational level , economic status , and social adjustment were examined as a function of early childhood treatment . Treated individuals attained significantly more years of education , but income-to-needs ratios and criminal involvement did not vary significantly as a function of early treatment . A number of other indicators were described for each domain . Overall , the findings provide strong evidence for educational benefits , mixed evidence for economic benefits , and little evidence for treatment-related social adjustment outcomes . Implication s for public policy are discussed The  Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on  cancer screening rates within the framework of a r and omized controlled trial . Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence , which can not be used to make causal inferences 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 . IMPORTANCE Mothers and children living in adverse context s are at risk of premature death . OBJECTIVE To determine the effect of prenatal and infant/toddler nurse home visiting on  maternal and child mortality  during a 2-decade period ( 1990 - 2011 ) . DESIGN , SETTING , AND PARTICIPANTS A r and omized clinical trial was design ed originally to assess the home visiting program 's effect on pregnancy outcomes and maternal and child health through child age 2 years . The study was conducted in a public system of obstetric and pediatric care in Memphis , Tennessee . Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods , who were assigned to 1 of 4 treatment groups : treatment 1 ( transportation for prenatal care [ n = 166 ] ) , treatment 2 ( transportation plus developmental screening for infants and toddlers [ n = 514 ] ) , treatment 3 ( transportation plus prenatal/postpartum home visiting [ n = 230 ] ) , and treatment 4 ( transportation , screening , and prenatal , postpartum , and infant/toddler home visiting [ n = 228 ] ) . Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes . For determining mortality , background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 ( n = 704 ) . Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children . INTERVENTIONS Nurses sought to improve the outcomes of pregnancy , children 's health and development , and mothers ' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years . MAIN OUTCOMES AND MEASURES All-cause mortality in mothers and preventable-cause mortality in children ( sudden infant death syndrome , unintentional injury , and homicide ) derived from the National Death Index . RESULTS The mean ( SE ) 21-year maternal all-cause mortality rate was 3.7 % ( 0.74 % ) in the combined control group ( treatments 1 and 2 ) , 0.4 % ( 0.43 % ) in treatment 3 , and 2.2 % ( 0.97 % ) in treatment 4 . The survival contrast of treatments 1 and 2 combined with treatment 3 was significant ( P = .007 ) ; the contrast of treatments 1 and 2 combined with treatment 4 was not significant ( P = .19 ) , and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant ( post hoc P = .008 ) . At child age 20 years , the preventable-cause child mortality rate was 1.6 % ( 0.57 % ) in treatment 2 and 0.0 % ( SE not calculable ) in treatment 4 ; the survival contrast was significant ( P = .04 ) . CONCLUSIONS AND RELEVANCE Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged setting s. TRIAL REGISTRATION clinical trials.gov Identifier : NCT00708695 In 1992 , the US Department of Housing and Urban Development ( HUD ) and the US Department of Veterans Affairs ( VA ) established the HUD-VA Supported Housing ( HUD-VASH ) Program to provide integrated clinical and housing services to homeless veterans with psychiatric and /or substance abuse disorders at 19 sites . At four sites , 460 subjects were r and omly assigned to one of the three groups : ( 1 ) HUD-VASH , with both Section 8 vouchers and intensive case management ; ( 2 ) case management only ; and ( 3 ) st and ard VA care . A previous publication found HUD-VASH result ed in superior housing outcomes but yielded no benefits on clinical outcomes . Since many participants missed prescheduled visits during the follow-up period and follow-up rates were quite different across the groups , we reanalyzed these data using multiple imputation statistical methods to account for the missing observations . Significant benefits were found for HUD-VASH in drug and alcohol abuse outcomes that had not previously been identified OBJECTIVE People with psychiatric impairments ( primarily schizophrenia or a mood disorder ) are the largest and fastest-growing group of Social Security Disability Insurance ( SSDI ) beneficiaries . The authors investigated whether evidence -based supported employment and mental health treatments can improve vocational and mental health recovery for this population . METHOD Using a r and omized controlled trial design , the authors tested a multifaceted intervention : team-based supported employment , systematic medication management , and other behavioral health services , along with elimination of barriers by providing complete health insurance coverage ( with no out-of-pocket expenses ) and suspending disability review s. The control group received usual services .  Paid employment was the primary outcome measure , and overall mental health and quality of life were secondary outcome measures . RESULTS Overall , 2,059 SSDI beneficiaries with schizophrenia , bipolar disorder , or depression in 23 cities participated in the 2-year intervention . The teams implemented the intervention package with acceptable fidelity . The intervention group experienced more paid employment ( 60.3 % compared with 40.2 % ) and reported better mental health and quality of life than the control group . CONCLUSIONS Implementation of the complex intervention in routine mental health treatment setting s was feasible , and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life When the GUIDE TO COMMUNITY PREVENTIVE SERVICES :  Systematic Review s and Evidence -Based Recommendations ( the Guide ) is published in 2001 , it will represent a significant national effort in encouraging evidence -based public health practice in defined population s ( e.g. , communities or members of specific managed care plans ) . The Guide will make recommendations regarding public health interventions to reduce illness , disability , premature death , and environmental hazards that impair community health and quality of life . The Guide is being developed under the guidance of the Task Force on Community Preventive Services ( the Task Force)-a 15-member , nonfederal , independent panel of experts . Subject matter experts , method ologists , and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature review s of evidence of effectiveness , economic efficiency , and feasibility on which to base recommendations for community action . Contributors to the Guide are building on the experience of others to confront method ologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonr and omized design s and diverse measures of outcome and effectiveness . Persons who plan , fund , and implement population -based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors . When the Guide is complete , readers are encouraged to consider critically the value and relevance of its contents , the implementation of interventions the Task Force recommends , the ab and onment of interventions the Task Force does not recommend , and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness Drawing on coping re sources theory , we evaluate the impact of a  job search intervention on  depressive symptoms  in a r and omized field experiment at three follow-up periods covering two and one-half years . Baseline depressive symptoms , low social assertiveness , and financial hardship were identified as significant risk variables predicting depressive symptoms at follow-up . These variables then were used to identify high- and low-risk individuals in both experimental and control groups . Results indicated that the job search intervention had its primary impact on persons identified as being at higher risk for depression . Furthermore , the intervention had an impact on both the incidence and prevalence of more severe depressive symptoms among high-risk individuals Background . Early education interventions have been forwarded as a means for reducing social disparities in income and health in adulthood . We explore whether a successful early education intervention , which occurred between 1985 and 1989 , improved the employment rates , earnings and health of blacks relative to whites through 2008 . Methods . We used data from Project STAR ( Student Teacher Achievement Ratio ) , a four-year multi-center r and omized controlled trial of reduced class sizes in Tennessee involving 11,601 students . Students were initially r and omized within 79 schools to classes with 22 - 25 or 13 - 17 students . We linked subject records to Social Security Administration ( SSA ) earnings and disability data collected between 1997 and 2008—when the majority of subjects were between the ages of 18 and 28 . We focused our analysis on annual , rather than cumulative , measures of earnings and employment because educational attainment after high school might reduce earnings through age 23 . We considered three or more years of statistically significant positive ( or negative ) annual impacts to be a meaningful effect . Results . Project STAR improved cognition and high school graduation rates . These benefits were primarily realized among low-income and minority students . These early education benefits did not translate into reduced disability cl aims in adulthood for treated subjects . However , exposure to small class size increased employment for blacks , and increased earnings for black males ( p<0.05 ) . Exposure to small classes also led to an increase in earnings for white males . However , white females exposed to small classes experienced a net decline in earnings and employment across the later years of follow up ( p<0.05 ) , off setting any gains by white males . Conclusions . Exposure to small class size in grade s K-3 appears to improve earnings and employment for black males and earnings for white males , while reducing employment and earnings among white females Limiting the number of students per classroom in the early years has been shown to improve educational outcomes . Improved education is , in turn , hypothesized to improve health . The authors examined whether smaller class sizes affect  mortality through age 29 years and whether cognitive factors play a role . They used data from the Project Student Teacher Achievement Ratio , a 4-year multicenter r and omized controlled trial of reduced class sizes in Tennessee involving 11,601 students between 1985 and 1989 . Children r and omized to small classes ( 13 - 17 students ) experienced improved measures of cognition and academic performance relative to those assigned to regular classes ( 22 - 25 students ) . As expected , these cognitive measures were significantly inversely associated with mortality rates ( P < 0.05 ) . However , through age 29 years , students r and omized to small class size nevertheless experienced higher mortality rates than those r and omized to regular size classes ( hazard ratio ( HR ) = 1.58 , 95 % confidence interval ( CI ) : 1.07 , 2.32 ) . The groups at risk included males ( HR = 1.73 , 95 % CI : 1.05 , 2.85 ) , whites/Asians ( HR = 1.68 , 95 % CI : 1.04 , 2.72 ) , and higher income students ( HR = 2.20 , 95 % CI : 1.06 , 4.57 ) . The authors speculate that small classes might produce behavior changes that increase mortality through young adulthood that are stronger than the protective effects of enhanced cognition Homelessness affects HIV risk and health , but little is known about the longitudinal effects of rental assistance on the housing status and health of homeless and unstably housed people living with HIV/AIDS . Homeless/unstably housed people living with HIV/AIDS ( N = 630 ) were r and omly assigned to  immediate Housing Opportunities for People with AIDS ( HOPWA ) rental assistance or customary care .  Self-reported data , CD4 , and HIV viral load were collected at baseline , 6 , 12 , and 18 months . Results showed that housing status improved in both groups , with greater improvement occurring in the treatment group . At 18 months , 51 % of the comparison group had their own housing , limiting statistical power . Intent-to-treat analyses demonstrated significant reductions in medical care utilization and improvements in self-reported physical and mental health ; significant differential change benefiting the treatment group was observed for depression and perceived stress . Significant differences between homeless and stably housed participants were found in as-treated analyses for health care utilization , mental health , and physical health . HOPWA rental assistance improves housing status and , in some cases , health outcomes of homeless and unstably housed people living with HIV/AIDS 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 OBJECTIVES The purpose of this study was to test whether early education intervention influences maternal employment , education , fertility , and receipt of public assistance and health insurance . METHODS The Infant Health and Development Program is a r and omized trial of the efficacy of early education on the outcomes of 985 low-birthweight , premature children . Families in eight sites received either pediatric follow-up and referral ( follow-up only group ) or pediatric services plus early intervention services ( intervention group ) for the first 3 years of the child 's life . RESULTS Mothers in the intervention group were employed more months and returned to the work force earlier than those in the follow-up only group . Fertility and education were not associated with treatment . Mothers who had some college education received more months of public assistance in the intervention group compared with the follow-up only group . Mothers who were employed received more public assistance and public health insurance in the intervention group compared with the follow-up only group , when maternal employment was controlled . CONCLUSIONS Findings are discussed in terms of the recent emphasis on two-generational programs directed to providing health , welfare , and child care services to young children and their families The relationship between depressive symptoms in young adults , the quality of the early home environment , and early educational child care was investigated in young adults r and omly assigned to receive early childhood intervention in the Abecedarian study . Of the original 111 infants enrolled ( 98 % African American ) , 104 participated in an age-21 follow-up . Those who had early treatment reported fewer depressive symptoms . The protective effects of the early childhood program were further supported by a significant home environment by treatment interaction . Negative effects of lower quality home environments on young adult depressive symptoms were almost entirely offset by preschool treatment , whereas depressive symptoms increased as the quality of the early home environment decreased for those in the control group 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 , In a retrospective survey , 487 research projects approved by the Central Oxford Research Ethics Committee between 1984 and 1987 , were studied for evidence of publication bias . As of May , 1990 , 285 of the studies had been analysed by the investigators , and 52 % of these had been published . Studies with statistically significant results were more likely to be published than those finding no difference between the study groups ( adjusted odds ratio [ OR ] 2.32 ; 95 % confidence interval [ Cl ] 1.25 - 4.28 ) . Studies with significant results were also more likely to lead to a greater number of publications and presentations and to be published in journals with a high citation impact factor . An increased likelihood of publication was also associated with a high rating by the investigator of the importance of the study results , and with increasing sample size . The tendency towards publication bias was greater with observational and laboratory-based experimental studies ( OR = 3.79 ; 95 % Cl = 1.47 - 9.76 ) than with r and omised clinical trials ( OR = 0.84 ; 95 % Cl = 0.34 - 2.09 ) . We have confirmed the presence of publication bias in a cohort of clinical research studies . These findings suggest that conclusions based only on a review of published data should be interpreted cautiously , especially for observational studies . Improved strategies are needed to identify the results of unpublished as well as published studies CONTEXT Extensive observational evidence indicates that youth in high-poverty neighborhoods exhibit poor mental health , although not all children may be affected similarly . OBJECTIVE To use experimental evidence to assess whether gender and family health problems modify the mental health effects of moving from high- to low-poverty neighborhoods . DESIGN R and omized controlled trial . SETTING Volunteer low-income families in public housing in 5 US cities between 1994 - 1997 . PARTICIPANTS We analyze 4- to 7-year outcomes in youth aged 12 to 19 years ( n = 2829 , 89 % effective response rate ) in the Moving to Opportunity Study . INTERVENTION Families were r and omized to remain in public housing ( control group ) or to receive government-funded rental subsidies to move into private apartments ( experimental group ) . Intention-to-treat analyses included intervention interactions by gender and health vulnerability ( defined as prer and omization health/developmental limitations or disabilities in family members ) . MAIN OUTCOME MEASURES Past-year psychological distress ( Kessler 6 scale [ K6 ] ) and the Behavioral Problems Index ( BPI ) . Supplemental analyses used past-year major depressive disorder ( MDD ) . RESULTS Male gender ( P = .02 ) and family health vulnerability ( P = .002 ) significantly adversely modified the intervention effect on K6 scores ; male gender ( P = .01 ) , but not health vulnerability ( P = .17 ) , significantly adversely modified the intervention effect on the BPI .  Girls without baseline health vulnerabilities were the only subgroup to benefit on any outcome ( K6 : β = -0.21 ; 95 % CI , -0.34 to -0.07 ; P = .003 ; MDD : odds ratio = 0.42 ; 95 % CI , 0.20 to 0.85 ; P = .02 ) . For boys with health vulnerabilities , intervention was associated with worse K6 ( β = 0.26 ; 95 % CI , 0.09 to 0.44 ; P = .003 ) and BPI ( β = 0.24 ; 95 % CI , 0.09 to 0.40 ; P = .002 ) values . Neither girls with health vulnerability nor boys without health vulnerability experienced intervention benefits . Adherence-adjusted instrumental variable analysis found intervention effects twice as large . Patterns were similar for MDD , but estimates were imprecise owing to low prevalence . CONCLUSIONS Although some girls benefited , boys and adolescents from families with baseline health problems did not experience mental health benefits from housing mobility policies and may need additional program supports BACKGROUND Despite the imminent expansion of Medicaid coverage for low-income adults , the effects of exp and ing coverage are unclear . The 2008 Medicaid expansion in Oregon based on lottery drawings from a waiting list provided an opportunity to evaluate these effects . METHODS Approximately 2 years after the lottery , we obtained data from 6387 adults who were r and omly selected to be able to apply for Medicaid coverage and 5842 adults who were not selected . Measures included blood-pressure , cholesterol , and glycated hemoglobin levels ; screening for depression ; medication inventories ; and self-reported diagnoses , health status , health care utilization , and out-of-pocket spending for such services . We used the r and om assignment in the lottery to calculate the effect of Medicaid coverage . RESULTS We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions . Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication , but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5 % or higher . Medicaid coverage decreased the probability of a positive screening for depression ( -9.15 percentage points ; 95 % confidence interval , -16.70 to -1.60 ; P=0.02 ) , increased the use of many preventive services , and nearly eliminated catastrophic out-of-pocket medical expenditures . CONCLUSIONS This r and omized , controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years , but it did increase use of health care services , raise rates of diabetes detection and management , lower rates of depression , and reduce financial strain OBJECTIVES We explored whether a successful r and omized controlled trial of early education , the Carolina Abecedarian Project ( ABC ) , which enrolled infants from 1972 to 1977 at the Frank Porter Graham Child Development Institute in Chapel Hill , North Carolina , improved health outcomes and behaviors by 21 years of age . METHODS ABC r and omized 111 infants to receive an intensive early education program or nutritional supplements and parental counseling alone ; participants have been followed to the present day . We examined the effect of ABC on health outcomes and behavioral risk factors when participants were aged 21 years , and then explored the mediators of this relationship . RESULTS Relative to the control group , the ABC treatment group was previously found to have improved cognition and educational attainment . We found that the intervention also improved heath ( P = .05 ) and health behaviors ( P = .03 ) when participants were aged 21 years . These improvements in behaviors were not mediated by IQ , math and reading scores at 15 years of age , educational attainment , or health insurance . CONCLUSIONS Effective early education programs may improve health and reduce risky health behaviors in adulthood
target: 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 .
background: 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 .