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.
