This is the current release of the guideline.

Public health risk for serious illness and premature death

Prevention

Family Practice
Pediatrics
Preventive Medicine

Allied Health Personnel
Health Care Providers
Public Health Departments
Utilization Management

To provide recommendations on community interventions that target early childhood development, family housing, and culturally competent health care to improve health and promote healthy social environments

Populations living in social environments lacking in basic resources and having high public health risk for serious illness and premature death

1. Early childhood development programs
2. Family housing interventions
   • Tenant-based rental assistance programs
   • Mixed-income housing developments (considered but not recommended)
3. Culturally competent healthcare systems

Overall Outcomes Considered

• Effectiveness of interventions at mobilizing community resources to create a healthy and safe environment
• Risk for morbidity and mortality
• Benefits and harms of interventions
• Applicability of interventions to various settings and populations

Outcomes Considered for Early Childhood Development Programs

• Cognitive development
• Academic achievement
• Children’s behavioral and social outcomes
• Children’s health screening
• Family outcomes

Outcomes Considered for Housing Interventions

• Victimization of household members
• Neighborhood safety
• Housing hazards
• Youth risk behaviors
• Mental health status
• Physical health status

Outcomes Considered for Culturally Competent Healthcare

• Ethnic differentials in treatment and utilization
• Satisfaction with care
• Health status outcomes

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Early Childhood Development

For early childhood development programs, searches were conducted in five computerized databases: PsychINFO, Educational Resource Information Center (ERIC), Medline, Social Science Search, and the Head Start Bureau research database. Published annotated bibliographies on Head Start and other early childhood development research, reference lists of reviewed articles, meta-analyses, and Internet resources were also examined, as were referrals from specialists in the field. To be included in the reviews of effectiveness, studies had to:

• document an evaluation of an early childhood development program within the United States
• be published in English between 1965 and 2000
• compare outcomes among groups of people exposed to the intervention with outcomes among groups of people not exposed or less exposed to the intervention (whether the comparison was concurrent between groups or before-and-after within groups)
• measure outcomes defined by the analytic framework for the intervention

The literature search yielded a list of 2,100 articles. These titles and abstracts were screened to see that the article reported on an intervention study (as opposed to program process measures, description of curricula, and so on). On the basis of this screening, 350 articles were obtained and assessed for inclusion. Of these articles, most were excluded because they were descriptive reports and not intervention studies. Fifty-seven articles that met the inclusion criteria listed above were evaluated. Of these articles, 41 were subsequently excluded because of threats to validity, duplication of information provided in an already-included study, lack of a comparison group, or lack of an examination of outcomes specified in the analytic framework. The remaining 16 studies (in 23 reports) were considered qualifying studies, and the findings of this review are based on those studies.

Family Housing Programs

For family housing programs, searches were conducted in ten computerized databases: Avery Index to Architectural Periodicals, EBSCO Information Services' Academic Search™ Elite, HUD User Bibliographic Database, MarciveWeb Catalogue of U.S. Government Publications, ProQuest Dissertations, ProQuest General Research Databases, PsychINFO, Public Affairs Information Services, Social Sciences Citation Index, and Sociological Abstracts. Internet resources were examined, as were reference lists of reviewed articles and referrals from specialists in the field. To be included in the reviews of effectiveness, studies had to:

• document an evaluation of a mixed-income housing development or a tenant-based rental assistance program for families within the United States
• be published in English between 1965 and 2000
• compare outcomes among groups of people exposed to the intervention with outcomes among groups of people not exposed or less exposed to the intervention (whether the comparison was concurrent between groups or before-and-after within groups)
• measure outcomes defined by the analytic framework for the intervention

For review of mixed-income housing developments, the team examined 312 citations (titles and abstracts) identified through the database search, review of pertinent reference lists, and consultation with housing specialists. These titles and abstracts were screened to determine if the report or article described a comparative intervention study (as opposed to program descriptions, general statistics on mixed-income developments, case studies, and so on). Based on this screening, 41 articles, reports, and dissertations were obtained and evaluated for inclusion, but none met the inclusion criteria listed above.

For the review of tenant-based rental assistance programs, the literature searches yielded 509 citations, of which 56 were obtained and evaluated for inclusion. Of these, 33 were excluded because they did not evaluate a relevant intervention or they lacked a comparative study design. Twenty-three articles and reports were considered qualifying studies and the findings in this review are based on those studies.

Culturally Competent Healthcare

Guideline developers searched eight databases for studies evaluating interventions to increase cultural competence in healthcare systems: Medline, ERIC, Sociological Abstracts, SciSearch, Dissertation Abstracts, Social Science Abstracts, Mental Health Abstracts, and HealthSTAR. Internet resources were examined, as were reference lists of reviewed articles and referrals from specialists in the field. To be included in the reviews of effectiveness, studies had to:

• document an evaluation of a healthcare system intervention to increase cultural or linguistic competence
• be conducted in an Established Market Economy
• be published in English between 1965 and 2001
• compare outcomes among groups of people exposed to the intervention with outcomes among groups of people not exposed or less exposed to the intervention (whether the comparison was concurrent between groups or before-and-after within groups)
• measure outcomes defined by the analytic framework for the intervention

The literature search yielded a list of 984 articles and reports. These titles and abstracts were screened to see if the article reported an intervention study (as opposed to studies of ethnic differentials in treatment or outcomes without an intervention component, descriptions of model programs, description of curricula for cultural competence, and so on). Based on this screening, 157 articles were assessed for inclusion. Nine articles met the inclusion criteria described here; three of these were excluded because of threats to validity. The remaining six studies were considered qualifying studies and the finding of this review are based on those studies.

Searching for and Retrieving Economic Evidence

The databases Medline, TRIS, CHID, NTIS, Embase, EI Compendex, PsycINFO, Social Science Search, Socio-logical Abstracts, ECONLIT, and Dissertation Abstracts were searched for the period 1970–2000. In addition, the references listed in all retrieved articles were reviewed and experts were consulted. Most of the included studies were either government reports or published in journals. To be included in the review a study had to:

• be a primary study rather than, for example, a guideline or review
• take place in an Established Market Economy
• be written in English
• meet the team’s definitions of the recommended intervention
• use economic analytic methods such as cost analysis, cost-effectiveness analysis, cost-utility analysis, or cost-benefit analysis (see Appendix A)
• itemize program costs and costs of illness or injury averted

Early childhood development: Sixteen qualifying studies
Mixed-income housing developments: No qualifying studies
Tenant-based rental voucher programs: Twenty-three qualifying articles and reports
Cultural competency: Six qualifying studies

Weighting According to a Rating Scheme (Scheme Given)

The strength of the body of evidence of effectiveness was characterized as strong, sufficient, or insufficient on the basis of the number of available studies, the suitability of study designs for evaluating effectiveness, the quality of execution of the studies, the consistency of the results, and the effect size.

Systematic Review with Evidence Tables

Other

Task Force recommendations are based primarily on the effectiveness of interventions as determined by the systematic literature review process. In making recommendations, the Task Force balances information about the effectiveness of an intervention with information about other potential benefits and potential harms. To determine how widely a recommendation should apply, the Task Force also considers the applicability of the intervention in various settings and populations. Finally, the Task Force reviews economic analyses of those interventions found to be effective and summarizes applicable barriers to intervention implementation. Economic information is provided to assist the reader with decision making but generally does not affect the Task Force’s recommendation.

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

Each of the "Recommended" or "Strongly Recommended" interventions included a systematic review of information from economic evaluations. The results of those evaluations are available in the companion documents.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

Recommendations from the National Education Goals panel, and Institute of Medicine were reviewed.

The guideline was submitted for extensive peer review, including review at various stages by a "consultant team," an external team of subject matter and methodologic experts, and peer review of the finished product by agencies and professional groups.

The relationship between the strength of evidence of effectiveness and the strength of the recommendation is defined at the end of the "Major Recommendations" field.

Intervention Recommendations

The Task Force evaluated the evidence of effectiveness for three types of interventions that mobilize community resources to create a healthy and safe environment: early childhood development, family housing, and culturally competent health care. These reviews focus on social resources that have an effect on individual risk for morbidity and mortality. A detailed review of evidence for each intervention topic can be found in the companion articles to the original guideline document.

Early Childhood Development Programs

Child development is a powerful determinant of health in adult life: One indication of this is the strong relationship between measures of educational attainment and adult disease. The early years of life are a period of considerable opportunity for growth and vulnerability to harm. Children affected by poverty are especially vulnerable: A socioeconomic gradient effect in early life has been found in cognitive and behavioral development, and this modifiable socioeconomic factor affects readiness for school.

Early childhood development programs are designed to promote social competence and school readiness in children aged 3 to 5 years. Publicly funded programs such as Head Start target preschool children disadvantaged by poverty. The holistic view of the child incorporated by such programs addresses cognitive, social, emotional, and physical development, as well as the ability of the child’s family to provide a home environment appropriate for healthy development. The health component of early childhood programs includes health screenings. The parental component provides job training and employment opportunities and encourages participation in social programs, ultimately supporting the child in all areas.

A child’s readiness when starting school is related to motivation and intellectual performance in subsequent years; initial readiness is critical to establishing a trajectory for success in educational attainment. Improved social cognition and higher educational attainment are important intermediary determinants of health risk behaviors.

Comprehensive, center-based, early childhood development programs for low-income children: recommended on the basis of strong evidence of improved cognitive development and academic achievement. The Task Force looked for evidence of improvement in four general areas: cognitive development and academic achievement, children’s behavioral and social outcomes, children’s health screening, and family outcomes. Evidence of improved cognitive development and academic achievement was strong, and on the basis of their effectiveness in decreasing retention in grade and decreasing placements in special education classes, the Task Force recommends publicly-funded, center-based, comprehensive early childhood development programs for low-income children aged 3 to 5 years.

Evidence was insufficient, however, to determine the effects of early childhood development programs on children’s social outcomes, children’s health screening outcomes, or family outcomes, primarily because too few studies of sufficient design and execution examined these outcomes. Although the body of published research is large, relatively few studies assess program impact in areas beyond cognitive gains (i.e., longer-term measures of health, well-being, and life success).

Family Housing Interventions

Social, physical, and economic characteristics of neighborhoods have both short- and long-term consequences for residents’ health and quality of life. An inadequate supply of affordable housing for low-income households and the increasing spatial (residential) segregation of households by income, race and ethnicity, or social class into unsafe neighborhoods are pressing community health issues. Neighborhood conditions affect residents’ opportunities in terms of quality of schools and other public services, economic viability of retail goods and services, crime and physical disarray, and opportunities to establish social networks across income groups. The physical and social conditions of neighborhoods are important for promoting healthy behaviors and positive life choices, for sustaining the ability of informal networks to circulate information about employment opportunities and available health resources, and for maintaining the capacity of formal and informal institutions to maintain public order. The Task Force reviewed the effects on these outcomes of two housing interventions aimed at providing affordable housing to low-income families and decreasing residential segregation by socioeconomic status: tenant-based rental assistance ("voucher") programs and mixed-income housing developments.

Tenant-based rental assistance programs: recommended. Tenant-based rental assistance programs, supported by public housing funds, use vouchers to subsidize the cost of housing secured by low-income households in the private rental market. Because these programs give participants a range of rental options, participants are less likely than residents of public housing projects to live in high-poverty neighborhoods. On the basis of sufficient evidence of effectiveness in improving outcomes of reduced victimization of household members (i.e., being mugged, beaten or assaulted, stabbed, or shot) and improved neighborhood safety (i.e., reduction of public drinking, public drug use, seeing person carrying weapon, or hearing gunfire), the Task Force recommends housing subsidy programs that provide low-income families with rental vouchers for use in the private housing market and allow families choice in residential location.

Evidence is insufficient to determine the effects of tenant-based rental assistance programs on housing hazards, youth risk behaviors, mental health status, or physical health status.

Mixed-income housing developments: insufficient evidence to determine effectiveness. Creation of mixed-income housing developments is one approach for increasing local socioeconomic heterogeneity and preventing or reversing neighborhood physical and social deterioration, while expanding the supply of decent, affordable housing. The Task Force, however, found no qualifying studies. As a result, there is insufficient evidence to determine the effectiveness of this intervention. A need for further research in this area is discussed in the accompanying review article.

Culturally Competent Healthcare Systems

An important factor hindering a more beneficial relationship between a growing ethnically diverse U.S. population and our healthcare systems is the lack of both culturally sensitive and linguistically appropriate services. Ethnic disparities in health outcomes can result from differential access to services because of direct or indirect discrimination, diagnostic errors resulting from misunderstanding of language, and failure to attend to culturally based health beliefs and practices.

Culturally competent healthcare systems are intended to remove the barriers to access caused by discrimination as well as differences in language and culturally based health practices, and ultimately to decrease ethnic disparities in health status. The Task Force examined five relevant interventions: programs to recruit and retain staff who reflect the cultural diversity of the community served, use of interpreter services or bilingual providers for clients with limited English proficiency, cultural competency training for healthcare providers, use of linguistically and culturally appropriate health education materials, and culturally specific healthcare settings. Evidence was insufficient to determine the effectiveness of any of these interventions to reduce ethnic differentials in treatment and utilization, improve satisfaction with care, or improve health status outcomes. Of particular note was the lack of comparison or control groups against which to compare culturally competent interventions with interventions less informed by the language or culture of the client population. A need for further research in this area is discussed in the accompanying review article.

Definitions:

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

None provided

The recommendations are based on qualifying studies, all of which had good or fair execution quality. In general, the strength of evidence of effectiveness corresponds directly to the strength of recommendations (see the "Major Recommendations" field).

Detailed descriptions of the evidence are provided in the companion documents to the original guideline document.

Recommended interventions can be used to achieve objectives set out in Healthy People 2010. In addition, the recommendations complement relevant goals and objectives set by the U.S. Department of Education, the Department o Health and Human Services (DHHS) Head Start Program, the U.S. Department of Housing and Urban Development, and the DHHS Office of Minority Health Recommended Standards for Culturally and Linguistically Appropriate Health Care Services.

Rental Assistance Programs

Rental assistance programs encourage families to move to neighborhoods of greater prosperity; this may disrupt the social ties and supports in the old neighborhood, resulting in its increased social deterioration. Overrepresentation of Section 8 families in receiving neighborhoods, particularly weaker or declining neighborhoods where more moderately priced housing may exist, could possibly destabilize those neighborhoods and create new areas of poverty. The team conducted additional literature searches to determine if the intervention had negative consequences for the neighborhoods of poverty from which families moved (i.e., disruption of social ties and networks, depleting neighborhoods of human capital, and furthering neighborhood decline) and none were identified. The potential for destabilization of receiving neighborhoods was raised in the literature, but no data were found documenting this outcome.

• The recommendations in this report represent the work of the independent, nonfederal Task Force on Community Preventive Services (the Task Force). The Task Force is developing the Guide to Community Preventive Services (the Community Guide) with the support of the U.S. Department of Health and Human Services (DHHS) in collaboration with public and private partners. The Centers for Disease Control and Prevention (CDC) provides staff support to the Task Force for development of the Community Guide.
• The strength of each recommendation is based on the strength of the evidence of effectiveness (e.g., an intervention is strongly recommended when there is strong evidence of effectiveness, and recommended when there is sufficient evidence). Other types of evidence can also affect a recommendation. For example, evidence of harms resulting from an intervention might lead to a recommendation that the intervention not be used if adverse effects outweigh improved outcomes. In general, the Task Force does not use economic information to modify recommendations.
• A finding of insufficient evidence of effectiveness should not be seen as evidence of ineffectiveness, but rather reflects the fact that the systematic review did not identify enough information for the Task Force to make a recommendation. Further, it is important for identifying areas of uncertainty that require additional research. In contrast, sufficient or strong evidence of ineffectiveness leads to a recommendation that the intervention not be used.
• The Task Force recognizes that a body of relevant social science literature was excluded from the reviews of effectiveness reported in companion documents because it lacked relevant comparisons. The excluded literature is rich and valuable for several purposes, such as assessing the need for programs, generating hypotheses, describing programs, assessing the fidelity with which programs were implemented, and many others. However, the Task Force thought this literature was less reliable for attributing effects to programmatic efforts and it was therefore not the primary focus of this review. Nonetheless, considerable use of the excluded literature in choosing topics, developing logic and analytic frameworks, and providing implementation advice has been made.

Use of Recommendations in Communities

Interventions that improve children's opportunities to learn and develop capacity should be relevant to all communities. These interventions are particularly important for children in communities with high rates of poverty, violence, substance abuse, and physical and social disorder. Children with multiple risks benefit most from early childhood development interventions.

Communities can assess the quality and availability of center-based early childhood development programs in terms of local needs and resources and can use the Task Force recommendation to advocate for continued or expanded funding of early childhood development programs. Current levels of federal and state funding are not adequate to support accessible quality services for the number of children at risk who would benefit from participation. The Task Force recommendation can be used as the evidence of effectiveness for those making policy and funding decisions. Health-care providers can use the recommendation to promote participation in an early childhood development program as part of well-child care. Public health agencies can use the Task Force recommendation to inform the community regarding the importance of early childhood development opportunities and their long-lasting effects on a child's well-being and ability to learn.

It is beyond the scope of this report to provide "how to" advice on implementing these programs. However, such advice is available through other early childhood development studies and entities.

Given the complexities of human development, no single intervention is likely to protect a child completely or permanently from the effects of harmful exposures, preintervention or postintervention. The guideline developers expect that these interventions will be most useful and effective as part of a coordinated system of supportive services for families (e.g., child care, housing and transportation assistance, nutritional support, employment opportunities, and health care).

Grassroots organizations, community advocacy groups, and resident stakeholders are in key positions to assess affordable housing needs within their own communities. Public housing assistance does not reach a large proportion of low-income families. An ongoing statewide assessment of housing affordability, availability, and quality can provide data for community organizations, elected officials, policy makers, and public agencies to stimulate the development of resources to meet local needs.

The Task Force recommendation can be used by public health agencies in conjunction with local housing authorities to inform policy makers of the effectiveness of rental voucher programs for increasing family safety in the neighborhood environment. The recommendations could serve as an impetus for local health departments, which provide families with comprehensive services, to assess and monitor the effects of housing conditions on health. Working with public health and local housing agencies, community-based housing advocates and urban planning and community development groups can advocate for continued and expanded funding for housing resources adequate to sustain family safety and residential stability and thus support a healthy community.

Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2003 Apr

Task Force on Community Preventive Services - Independent Expert Panel

U.S. Department of Health and Human Services; Centers for Disease Control and Prevention (CDC)

Task Force on Community Preventive Services

Task Force Members: Jonathan E. Fielding, MD, MPH, MBA (Chair), Los Angeles Department of Health Services, Los Angeles, California; Patricia Dolan Mullen, DrPH (Vice-Chair), University of Texas-Houston School of Public Health, Houston, Texas; John Clymer, Partnership for Prevention, Washington, D.C.; Mindy Thompson Fullilove, MD, New York State Psychiatric Institute and Columbia University, New York, New York; Alan R. Hinman, MD, MPH, Task Force for Child Survival and Development, Atlanta, Georgia; George J. Isham, MD, HealthPartners, Minneapolis, Minnesota; Robert L. Johnson, MD, New Jersey Medical School, Department of Pediatrics, Newark, New Jersey; Garland H. Land, MPH, Center for Health Information Management and Epidemiology, Missouri Department of Health, Jefferson City, Missouri; Noreen Morrison Clark, PhD, University of Michigan School of Public Health, Ann Arbor, Michigan; Patricia A. Nolan, MD, MPH, Rhode Island Department of Health, Providence, Rhode Island; Dennis E. Richling, MD, Union Pacific Railroad, Omaha, Nebraska; Barbara K. Rimer, DrPH, School of Public Health University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Steven M. Teutsch, MD, MPH, Merck & Company, Inc., West Point, Pennsylvania

Consultants: Robert S. Lawrence, MD, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; J. Michael McGinnis, MD, Robert Wood Johnson Foundation, Princeton, New Jersey; Lloyd F. Novick, MD, MPH, Onondaga County Department of Health, Syracuse, New York

Former Members who served during guideline development: Caswell A. Evans, Jr., DDS, MPH, Former Task Force Chair; Los Angeles County Department of Health Services, Los Angeles, California; Current affiliation: Director, National Oral Health Initiative, Office of the U.S. Surgeon General, Rockville, Maryland; Ross Brownson, PhD, St. Louis University School of Public Health, St. Louis, Missouri; Patricia A. Buffler, PhD, MPH, School of Public Health, University of California, Berkeley; Mary Jane England, MD, Regis College, Weston, Massachusetts; David W. Fleming, MD, Bill & Melinda Gates Foundation, Seattle, WA; Fernando A. Guerra, MD, MPH, San Antonio Metropolitan Health District, San Antonio, Texas; Charles S. Mahan, MD, University of South Florida College of Public Health, Tampa, Florida; Susan C. Scrimshaw, PhD, University of Illinois School of Public Health, Chicago, Illinois; Robert S. Thompson, MD, Department of Preventive Care, Group Health Cooperative of Puget Sound, Seattle, Washington

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on May 28, 2004. The information was verified by the guideline developer on July 9, 2004.

No copyright restrictions apply.