Early Childhood Education: Health, Equity, and Economics.

Many low-income and minority children in the United States and globally are at risk of poor educational trajectories and, consequently, diminished life courses, because their households and neighborhoods lack resources to adequately support learning and development prior to formal schooling. This review summarizes evidence on center-based early childhood education (ECE) for three- and four-year-olds as a means of assuring school readiness in cognitive and socioemotional skills. While the details of ECE programs merit further research, it is clear that ECE can benefit children, especially those most disadvantaged, with additional societal benefits and positive long-run economic returns. Universal ECE is not a cure-all, and its success requires ongoing alignment with subsequent education and attention to child household and community conditions. Because resource deprivation is concentrated in low-income and minority communities, publicly funded universal ECE can also be a powerful instrument for the promotion of social equity.

Tenant-Based Housing Voucher Programs: A Community Guide Systematic Review.

CONTEXT: Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing. OBJECTIVE: To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income. DESIGN: Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched. ELIGIBILITY CRITERIA: Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior. RESULTS: Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry. CONCLUSION: Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review.

CONTEXT: Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. OBJECTIVES: A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. DESIGN: A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. ELIGIBILITY CRITERIA: Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing stability, physical and mental health outcomes, and health care utilization. RESULTS: Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. CONCLUSIONS: Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

Expanded In-School Instructional Time and the Advancement of Health Equity: A Community Guide Systematic Review.

Expanded in-school instructional time (EISIT) may reduce racial/ethnic educational achievement gaps, leading to improved employment, and decreased social and health risks. When targeted to low-income and racial/ethnic minority populations, EISIT may thus promote health equity. Community Guide systematic review methods were used to search for qualified studies (through February 2015, 11 included studies) and summarize evidence of the effectiveness of EISIT on educational outcomes. Compared with schools with no time change, schools with expanded days improved students' test scores by a median of 0.05 standard deviation units (range, 0.0-0.25). Two studies found that schools with expanded day and year improved students' standardized test scores (0.04 and 0.15 standard deviation units). Remaining studies were inconclusive. Given the small effect sizes and a lack of information about the use of added time, there is insufficient evidence to determine the effectiveness of EISIT on academic achievement and thus health equity.

Examining the Effectiveness of Year-Round School Calendars on Improving Educational Attainment Outcomes Within the Context of Advancement of Health Equity: A Community Guide Systematic Review.

Students may lose knowledge and skills achieved in the school year during the summer break, with losses greatest for students from low-income families. Community Guide systematic review methods were used to summarize evaluations (published 1965-2015) of the effectiveness of year-round school calendars (YRSCs) on academic achievement, a determinant of long-term health. In single-track YRSCs, all students participate in the same school calendar; summer breaks are replaced by short "intersessions" distributed evenly throughout the year. In multi-track YRSCs, cohorts of students follow separate calendar tracks, with breaks at different times throughout the year. An earlier systematic review reported modest gains with single-track calendars and no gains with multi-track calendars. Three studies reported positive and negative effects for single-track programs and potential harm with multi-track programs when low-income students were assigned poorly resourced tracks. Lack of clarity about the role of intersessions as simple school breaks or as additional schooling opportunities in YRSCs leaves the evidence on single-track programs insufficient. Evidence on multi-track YRSCs is also insufficient.

Trends in Mortality Among Females in the United States, 1900-2010: Progress and Challenges.

INTRODUCTION: We analyzed trends in US female mortality rates by decade from 1900 through 2010, assessed age and racial differences, and proposed explanations and considered implications. METHODS: We conducted a descriptive study of trends in mortality rates from major causes of death for females in the United States from 1900 through 2010. We analyzed all-cause unadjusted death rates (UDRs) for males and females and for white and nonwhite males and females from 1900 through 2010. Data for blacks, distinct from other nonwhites, were available beginning in 1970 and are reported for this and following decades. We also computed age-adjusted all-cause death rates (AADRs) by the direct method using age-specific death rates and the 2000 US standard population. Data for the analysis of decadal trends in mortality rates were obtained from yearly tabulations of causes of death from published compilations and from public use computer data files. RESULTS: In 1900, UDRs and AADRs were higher for nonwhites than whites and decreased more rapidly for nonwhite females than for white females. Reductions were highest among younger females and lowest among older females. Rates for infectious diseases decreased the most. AADRs for heart disease increased 96.5% in the first 5 decades, then declined by 70.6%. AADRs for cancer rose, then decreased. Stroke decreased steadily. Unintentional motor vehicle injury AADRs increased, leveled off, then decreased. Differences between white and nonwhite female all-cause AADRs almost disappeared during the study period (5.4 per 100,000); differences in white and black AADRs remained high (121.7 per 100,000). CONCLUSION: Improvements in social and environmental determinants of health probably account for decreased mortality rates among females in the early 20th century, partially offset by increased smoking. In the second half of the century, other public health and clinical measures contributed to reductions. The persistent prevalence of risk behaviors and underuse of preventive and medical services indicate opportunities for increased female longevity, particularly in racial minority populations.

Early Childhood Education to Promote Health Equity: A Community Guide Economic Review.

CONTEXT: A recent Community Guide systematic review found that early childhood education (ECE) programs improve educational, social, and health-related outcomes and advance health equity because many are designed to increase enrollment for high-risk children. This follow-up economic review examines how the economic benefits of center-based ECE programs compare with their costs. EVIDENCE ACQUISITION: Kay and Pennucci from the Washington State Institute for Public Policy, whose meta-analysis formed the basis of the Community Guide effectiveness review, conducted a benefit-cost analysis of ECE programs for low-income children in Washington State. We performed an electronic database search using both effectiveness and economic key words to identify additional cost-benefit studies published through May 2015. Kay and Pennucci also provided us with national-level benefit-cost estimates for state and district and federal Head Start programs. EVIDENCE SYNTHESIS: The median benefit-to-cost ratio from 11 estimates of earnings gains, the major benefit driver for 3 types of ECE programs (ie, state and district, federal Head Start, and model programs), was 3.39:1 (interquartile interval [IQI] = 2.48-4.39). The overall median benefit-to-cost ratio from 7 estimates of total benefits, based on all benefit components including earnings gains, was 4.19:1 (IQI = 2.62-8.60), indicating that for every dollar invested in the program, there was a return of $4.19 in total benefits. CONCLUSIONS: ECE programs promote both equity and economic efficiency. Evidence indicates there is positive social return on investment in ECE irrespective of the type of ECE program. The adoption of a societal perspective is crucial to understand all costs and benefits of ECE programs regardless of who pays for the costs or receives the benefits.

High School Completion Programs: A Community Guide Systematic Economic Review.

CONTEXT: On-time high school graduation rate is among the 26 leading health indicators for Healthy People 2020. High school completion (HSC) programs aim to increase the likelihood that students finish high school and receive a high school diploma or complete a GED (General Educational Development) program. This systematic review was conducted to determine the economic impact of HSC interventions, assess variability in cost-effectiveness of different types of programs, and compare the lifetime benefit of completing high school with the cost of intervention. EVIDENCE ACQUISITION: Forty-seven included studies were identified from 5303 articles published in English from January 1985 to December 2012. The economic evidence was summarized by type of HSC program. All monetary values were expressed in 2012 US dollars. The data were analyzed in 2013. EVIDENCE SYNTHESIS: Thirty-seven studies provided estimates of incremental cost per additional high school graduate, with a median cost for HSC programs of $69 800 (interquartile interval = $35 900-$130 300). Cost-effectiveness ratios varied depending on intervention type, study settings, student populations, and costing methodologies. Ten studies estimated the lifetime difference of economic benefits between high school nongraduates and graduates; 4 used a governmental perspective and reported benefit per additional high school to range from $187 000 to $240 000; 6 used a societal perspective and reported a range of $347 000 to $718 000. Benefits exceeded costs in most studies from a governmental perspective and in all studies from a societal perspective. CONCLUSION: Interventions to increase HSC rates produce substantial economic benefits to government and society including averted health care costs. From a societal perspective, the benefits also exceed costs, implying a positive rate of return from investment in HSC programs.

Early Childhood Education to Promote Health Equity: A Community Guide Systematic Review.

CONTEXT: Children in low-income and racial and ethnic minority families often experience delays in development by 3 years of age and may benefit from center-based early childhood education. DESIGN: A meta-analysis on the effects of early childhood education by Kay and Pennucci best met Community Guide criteria and forms the basis of this review. RESULTS: There were increases in intervention compared with control children in standardized test scores (median = 0.29 SD) and high school graduation (median = 0.20 SD) and decreases in grade retention (median = 0.23 SD) and special education assignment (median = 0.28 SD). There were decreases in crime (median = 0.23 SD) and teen births (median = 0.46 SD) and increases in emotional self-regulation (median = 0.21 SD) and emotional development (median = 0.04 SD). All effects were favorable, but not all were statistically significant. Effects were also long-lasting. CONCLUSIONS: Because many programs are designed to increase enrollment for high-risk students and communities, they are likely to advance health equity.

Education Improves Public Health and Promotes Health Equity.

This article describes a framework and empirical evidence to support the argument that educational programs and policies are crucial public health interventions. Concepts of education and health are developed and linked, and we review a wide range of empirical studies to clarify pathways of linkage and explore implications. Basic educational expertise and skills, including fundamental knowledge, reasoning ability, emotional self-regulation, and interactional abilities, are critical components of health. Moreover, education is a fundamental social determinant of health - an upstream cause of health. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are needed to promote health equity. Public health policy makers, health practitioners and educators, and departments of health and education can collaborate to implement educational programs and policies for which systematic evidence indicates clear public health benefits.

Out-of-School-Time Academic Programs to Improve School Achievement: A Community Guide Health Equity Systematic Review.

CONTEXT: Low-income and minority status in the United States are associated with poor educational outcomes, which, in turn, reduce the long-term health benefits of education. OBJECTIVE: This systematic review assessed the extent to which out-of-school-time academic (OSTA) programs for at-risk students, most of whom are from low-income and racial/ethnic minority families, can improve academic achievement. Because most OSTA programs serve low-income and ethnic/racial minority students, programs may improve health equity. DESIGN: Methods of the Guide to Community Preventive Services were used. An existing systematic review assessing the effects of OSTA programs on academic outcomes (Lauer et al 2006; search period 1985-2003) was supplemented with a Community Guide update (search period 2003-2011). MAIN OUTCOME MEASURE: Standardized mean difference. RESULTS: Thirty-two studies from the existing review and 25 studies from the update were combined and stratified by program focus (ie, reading-focused, math-focused, general academic programs, and programs with minimal academic focus). Focused programs were more effective than general or minimal academic programs. Reading-focused programs were effective only for students in grades K-3. There was insufficient evidence to determine effectiveness on behavioral outcomes and longer-term academic outcomes. CONCLUSIONS: OSTA programs, particularly focused programs, are effective in increasing academic achievement for at-risk students. Ongoing school and social environments that support learning and development may be essential to ensure the longer-term benefits of OSTA programs.

School Segregation Reduces Life Expectancy in the U.S. Black Population by 9 Years.

Despite the 1954 Brown versus Board of Education Supreme Court decision, school segregation of U.S. blacks persists. Given the powerful role of education as a social determinant, health consequences of school segregation are likely to be substantial. This study indicates the causal link between school segregation and high school graduation and the association of graduation and life expectancy. It estimates the reduction in life expectancy associated with school segregation and characterizes the prevalence of school segregation of black students in states. Lack of high school completion is associated with a reduction in life expectancy of 9 years-similar to that of smoking. The prevalence of black school segregation (>50% minority) is greatest in the Northeast (81.1%), next highest in the South (78.1), next in the Midwest (68.4%), and lowest in the West (13.6%). Known remedies to school segregation must be implemented to eliminate this root of health inequity.

Permanent Supportive Housing With Housing First: Findings From a Community Guide Systematic Economic Review.

INTRODUCTION: The annual economic burden of chronic homelessness in the U.S. is estimated to be as high as $3.4 billion. The Permanent Supportive Housing with Housing First (Housing First) program, implemented to address the problem, has been shown to be effective. This paper examines the economic cost and benefit of Housing First Programs. METHODS: The search of peer-reviewed and gray literature from inception of databases through November 2019 yielded 20 evaluation studies of Housing First Programs, 17 from the U.S. and 3 from Canada. All analyses were conducted from March 2019 through July 2020. Monetary values are reported in 2019 U.S. dollars. RESULTS: Evidence from studies conducted in the U.S. was separated from those conducted in Canada. The median intervention cost per person per year for U.S. studies was $16,479, and for all studies, including those from Canada, it was $16,336. The median total benefit for the U.S. studies was $18,247 per person per year, and it was $17,751 for all studies, including those from Canada. The benefit-to-cost ratio for U.S. studies was 1.80:1, and for all studies, including those from Canada, it was 1.06:1. DISCUSSION: The evidence from this review shows that economic benefits exceed the cost of Housing First Programs in the U.S. There were too few studies to determine cost-benefit in the Canadian context.

What is a social determinant of health? Back to basics.

The objective of this essay is to clarify the understanding and use of Social Determinants of Health by exploring basic characteristics of 'determinants' and 'fundamental causes,' the 'social,' 'structure,' and 'modifiability,' and to consider theoretical and practical implications of this reconceptualization for public health.  The analysis distinguishes SDOH from other determinants of health. Social determinants of health are defined as mutable societal systems, their components, and the social resources and hazards for health that societal systems control and distribute, allocate and withhold, and that, in turn, cause health consequences, including changes in the demographic distributions and trends of health.  A systems conceptualization holds concepts such as "race" as the creations of social systems and as having negative consequences, such as racism, when part of a racist system, but potentially ameliorative consequences when part of an anti-racist system. The integration of SDOH into public health theory and practice may substantially expand the benefits of public health, but will require new theorizing, intervention research, education, collaboration, policy, and practice.

Estimating the COVID-Related Deaths Attributable to President Trump's Early Pronouncements About Masks.

The goal of this analysis is to estimate the proportion of COVID-19 deaths attributable to President Donald Trump's early pronouncements about voluntary mask use and his intention not to use masks. Data from available research were used to estimate parameters for the calculation of population attributable risk for COVID-19 deaths reported to date. Assuming Trump's pronouncement to have caused 25%, 50%, and 75% of the non-use of masks, estimates of Trump-attributable COVID-19 deaths to date would be, respectively, 4,244, 8,356, or 12,202. The effects of presidential pronouncements on health-related matters may have large public health consequences. Pronouncements of national leaders should be based on the best available science.

Access to Social Determinants of Health and Determinant Inequity for the Black Population in US States in the Early Twenty-First Century.

This analysis develops indices of (1) modifiable social determinants of health and (2) social determinant inequity and applies the indices to the black population in US states. It uses state data available between 2013 and 2018 stratified by black and white race on six social determinants covering a range of topics (high school non-completion, incarceration, non-home ownership, poverty, unemployment, and voter non-registration). Determinants are ranked by state on (1) limited determinant access by blacks and (2) on black-white determinant differences, i.e., inequity. For each state, ranks are summed for each determinant and determinant differences. Greater determinant access and greater equity are found in southern states. More limited access is found in northeastern and western states; lowest ranked of access is found in some midwestern states. Greatest equity is found in southern states; greatest inequity is found in midwestern states. Indices are associated with state rates of black self-reported health. Indices of social determinant access and inequity can be developed and applied to states for US minority populations. The indices promote attention to the differential distribution of social determinants, suggest the consequences of structural racism, and indicate targets for the redress of inequity.

Anthropological foundations of public health; the case of COVID 19.

OBJECTIVES: The complex societal spread of COVID-19 in the U.S. indicates a need to recognize sociocultural forces to best understand and respond to the pandemic. This essay describes four principles of anthropology and sister disciplines that underlie the theory and practice of public health. METHODS: Research following anthropological and related approaches is reviewed to provide examples of the four principles from COVID-19 in the U.S. RESULTS: 1. What counts as sickness, disease, injury, pathology, is fundamentally a matter of historically situated social ideas and values. 2. The ways in which societies are organized is a fundamental source of pathologies and their distributions within societies. 3. Conversely, health conditions can substantially alter the organization of societies. 4. Public health responses are social processes that affect intervention outcomes. CONCLUSIONS: Anthropological approaches are recommended to address several facets of public health practice: problem analysis, intervention design, evaluation, and the public health enterprise itself.

Survival in Adversity: Trends in Mortality Among Blacks in the United States, 1900-2010.

The goal of this study was to analyze trends in black age-adjusted mortality rates (AADR) from 1900 through 2010 and to propose explanations. Analyses included a descriptive study of trends in AADR from major causes for blacks and age-specific all-cause mortality at each decade. In 1900, all-cause AADRs were higher for blacks than whites. Over the century, differences decreased substantially. Reductions mortality were greatest among young people, lowest among older adults. Deaths from infectious diseases showed the greatest decrease. Heart disease mortality among blacks increased from 1920 to 1950, then decreased by 2010. For men and women, AADRs for cancer rose to a peak in 1990, then declined. Stroke mortality decreased steadily for males and females. AADRs from unintentional injuries (not including motor vehicle injury) decreased gradually. Despite widespread societal resistance, blacks have made substantial gains in a wide range of social determinants of health, such as civil rights, education, employment, income, and housing. Substantial gains remain to be made.

Why a Right to Health Makes No Sense, and What Does.

There is a widely held belief in a universal right to the highest attainable standard of health. This essay shows how this right is conceptually unclear, unattainable, and a distraction from a more concrete and attainable right: a right to equitable access to available resources for health (RARH), including equitable access to the social determinants of health. It clarifies conceptual and theoretical issues in the RARH: its underlying theory rooted in historical, economic, and axiological rationales; its concept of component resources and their availability, equity, sustainability; and the redistribution of wealth and power, metrics, and ethics. The advancement of global health equity requires explicit theorizing of what underlies a right to health. The right to the highest attainable standard of health fails in this regard. The RARH provides a desirable, actionable, and measurable foundation for global health equity.