Evaluation of a civic engagement approach to catalyze built environment change and promote healthy eating and physical activity among rural residents: a cluster (community) randomized controlled trial.

BACKGROUND: Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors. METHODS: This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation. DISCUSSION: Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

Synthesizing Econometric Evidence: The Case of Demand Elasticity Estimates.

Econometric estimates of the responsiveness of health-related consumer demand to higher prices are often key ingredients for risk policy analysis. We review the potential advantages and challenges of synthesizing econometric evidence on the price-responsiveness of consumer demand. We draw on examples of research on consumer demand for health-related goods, especially cigarettes. We argue that the overarching goal of research synthesis in this context is to provide policy-relevant evidence for broad-brush conclusions. We propose three main criteria to select among research synthesis methods. We discuss how in principle and in current practice synthesis of research on the price-elasticity of smoking meets our proposed criteria. Our analysis of current practice also contributes to academic research on the specific policy question of the effectiveness of higher cigarette prices to reduce smoking. Although we point out challenges and limitations, we believe more work on research synthesis in this area will be productive and important.

An analysis of life-course smoking behavior in China.

With a total population of more than 1.3 billion people where more than 31% of adults smoke, China has become the world's largest producer and consumer of cigarettes. We adopt a life-course perspective to study the economics of smoking behavior in China. We use data from the China Health and Nutrition Survey (CHNS) to follow individuals over their whole lives and to analyze their decisions to both start and stop smoking. We extend the small but growing body of economic research on smoking in China. Our life-course approach emphasizes that current smoking participation reflects a decision to start and a series of past decisions to not quit. We explore how the determinants of smoking initiation differ from the determinants of smoking cessation. We find results, consistent with some previous empirical evidence, that Chinese smoking is not strongly related to the price of cigarettes. Based on our results, we offer some speculative hypotheses that, we hope, might guide future research on the economics of smoking in China. It seems especially useful to compare the broad patterns we document with the experiences of other countries.

Cigarette taxes and the transition from youth to adult smoking: smoking initiation, cessation, and participation.

Many policy makers continue to advocate and adopt cigarette taxes as a public health measure. Most previous individual-level empirical studies of cigarette demand are essentially static analyses of the relationship between the level of taxes and smoking behavior at a point in time. In this study, we use longitudinal data to examine the dynamics of young adults' decisions about smoking initiation and cessation. We develop a simple model to highlight the distinctions between smoking initiation, cessation, and participation. We show that because smoking participation reflects past decisions regarding initiation and cessation, the price elasticity of smoking participation is a weighted average of corresponding initiation and cessation elasticities, a finding that applies more broadly to other addictive substances as well. The paper's remaining contributions are empirical. We use data from the 1992 wave of the National Education Longitudinal Study, when most of the cohort were high school seniors, and data from the 2000 wave, when they were about 26 years old. The results show that the distinction between initiation and cessation is empirically useful. We also contribute new estimates on the tax-responsiveness of young adult smoking, paying careful attention to the possibility of bias if hard-to-observe differences in anti-smoking sentiment are correlated with state cigarette taxes. We find no evidence that higher taxes prevent smoking initiation, but some evidence that higher taxes are associated with increased cessation.

The Economics of Personalization in Prevention and Public Health.

Personalized prevention uses family history and predictive genetic testing to identify people at high risk of serious diseases. The availability of predictive genetic tests is a newer and still-developing phenomenon. Many observers see tremendous potential for personalized prevention to improve public health. At the same time, the emergence of these new markets raises familiar health policy concerns about costs, cost-effectiveness, and health disparities. This paper first discusses an economic framework for the analysis of personalized prevention. On the demand side, consumers use personalized prevention as a form of information that allows them to make better choices about prevention, including medical care and health behaviors like diet and exercise. On the supply side, an interplay of complex market forces and regulations will determine the prices, advertising, and insurance coverage of predictive genetic tests. Beyond the question of whether health insurance will cover the costs of predictive genetic tests, there is a great deal of concern about whether consumers' use of genetic tests might place them at risk of genetic discrimination or might lead to adverse selection. The paper also reports descriptive analysis of data from the 2000, 2005, and 2010 National Health Interview Surveys on the use of predictive genetic tests. The empirical analysis documents large socioeconomic status-related disparities in consumers having heard of genetic tests: for example, consumers with less schooling, Blacks, and Hispanics were substantially less likely to have heard of genetic tests. Evidence from other empirical studies provides little evidence that genetic testing leads to genetic discrimination in insurance markets. There is more evidence suggesting adverse selection, where genetic testing leads consumers to purchase long-term care insurance. The paper concludes with some preliminary thoughts about important directions for future research. The goal of the paper is to review relevant research to help develop an economic approach and social science research agenda into the determinants and consequences of genetic tests for prevention.

Economic evaluation of the social determinants of health: an overview of conceptual and practical issues

"This report develops a framework for the economic evaluation of social determinants of health (SDH) interventions. The use of economic arguments, in particular regarding the “value for money” of suggested interventions, has so far been a low priority in recent major SDH initiatives, such as in the WHO Commission on Social Determinants of Health. At the same time, the need to add an economic perspective to the analysis of SDH and of health inequalities has been increasingly recognized in the public health community.Because any economic evaluation hinges on the evidence of effectiveness in the first place, a considerable share of our discussion focuses on the challenge of assessing whether a given intervention “works” (and if so, for whom it does). We stress the importance of using a research design that provides credible estimates of the causal impacts of the intervention under consideration, even in the absence of randomised experimental evidence. The approaches we propose, using quasi-experimental, econometric or structural models, can be used to provide credible estimates of the effectiveness of SDH interventions. In a framework for economic evaluation, the choice between these methods will usually depend on the existing research base and the practicality of new research on the causal impacts of the SDH intervention being evaluated.For the purpose of valuing the health improvements and indeed other non-health effects possibly resulting from SDH interventions, we recommend social cost-benefit analysis as the approach to develop a comprehensive measure that reflects the value of improving outcomes across multiple domains including health, earnings, and crime. We focus on the application of cost-benefit approaches to economic evaluations of SDH interventions.Last not least we discuss the implications of SDH interventions for health equity, and how distributional consequences might be taken into account in an economic evaluation. While there is growing acceptance among economists for the need to capture and take into account distributional consequences along-side economic evaluations, and while we also know that people are in principle willing to sacrifice overall health benefits for a reduction in health inequalities, a universally accepted method to incorporate the value of reducing health inequities into economic evaluations has yet to emerge. Instead, we may think of a hierarchy of approaches to incorporating equity considerations into economic evaluations of SDH interventions."