Easy-Bake Scaling Up: Natural Experiments in Housing & Health

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1 Easy-Bake Scaling Up: Natural Experiments in Housing & Health James R. Dunn, Ph.D. CIHR-PHAC Chair in Applied Public Health Associate Professor, Dept. of Health, Aging & Society, McMaster University Scientist, Centre for Research on Inner City Health, St. Michael s Hospital Fellow, Successful Societies Program, Canadian Institute for Advanced Research Deputy Editor, Journal of Epidemiology & Community Health

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3 Easy-Bake Oven Introduced by Kenner in 1963 Heat from 100W incandescent light bulb used to bake a cake Similar to natural experiment research in one respect.. Light bulb burns naturally and the oven is wrapped around it to create an environment that will bake cake...and not in another... No package of off-the-shelf cake ingredients available, you have to make your own recipes

4 Important Findings from Natural Experiments I Representative sample of 1,420 rural children undergo annual psychiatric assessments 25% are American Indian At the mid-point of the study, Indian reservation opens casino : residents receive income supplement 14% of families rise out of poverty (ex-poor), 53% stay poor, 32% were never poor

5 Important Findings from Natural Experiments I Before intervention, ex-poor and persistently poor had higher rates of psychiatric disorder After intervention, rates of psychiatric disorder for ex-poor to never-poor level Effects only on conduct and oppositional disorder depression and anxiety unaffected Costello, et al. (2003). Relationships between poverty and psychopathology. JAMA, 290(15)

6 Important Findings from Natural Experiments II Folic acid supplementation of bread & grain products began in Canada in 1998 Intended to reduce neural tube defects caused by folic acid insufficiency This kind of intervention needed: most pregnancies are unplanned, so voluntary supplementation is ineffective Ray, et al. (2004) found levels of folic acid in women; 2 nd study found NTDs

7 Important Findings from Natural Experiments III Flouridation of community water supplies considered a great achievement in dental public health Effect originally found in a natural experiment research in a place with naturally high flouride levels in the water supply Elevated bone cancer rates also shown by natural experiment studies

8 Important Findings from Natural Experiments IV U.S. Study used a register of Hiroshima survivors to recruit 3 groups of Japanese-born people : 1) migrants to California, 2) migrants to Hawaii and 3) people who stayed in Hiroshima Compared heart disease risk factors and mortality in the 3 groups Found worst outcomes in California immigrants, followed by Hawaii migrants, then non-movers Best study available on immigrant health Syme, Marmot, et al. (1975)

9 Important Findings from Natural Experiments V In Sept 2010, a NEJM study showed effects of indoor smoking ban in Scotland (2006) Study examined effect on children s hospital admissions for asthma ( ) Found reduced hospital admissions for child asthma that coincided with smoking ban Unexpected that this would have an impact outside of people working in bars why?

10 Why Natural Experiments? People & populations are often subjected to change that could affect their health If we can design studies to capture the health impacts of those changes, we can: Learn how existing policies & programs are working Where improvement could be helpful Observational studies give little insight into what works to improve health? Randomized Control Trials (RCTs) are often not feasible or unethical to conduct

11 Longitudinal Aspects of Natural Experiments Longitudinal aspects of natural experiments help to: Control for confounders comparing the same people pre- and post-intervention means many confounders are held constant Eliminate uncertainty in the direction of causality Increase statistical power to detect small changes Investigate how much time it takes for change to happen after intervention and how long it lasts

12 Other Benefits of Natural Experiments Usually have high external validity, providing indication of effectiveness (not efficacy) Can be compromised by low internal validity Can often determine effects of interventions on health inequalities (differential effects) e.g. effects by gender, immigration status, etc. Evidence from natural experiments may be more easily translated into policy Represents a real intervention, not an artificial one

13 Challenges of Natural Experiments Control or comparison groups researcher does not control allocation of subjects to intervention / comparison group May be systematic bias / selection into the groups May be difficult to find a comparison group that is not contaminated by the intervention Possibility of crossover during the study May be difficult to define the affected group Many interventions affecting inequalities are complex e.g., neighbourhood regeneration

14 Examples from Housing & Health Research Every day people change residential location Sometimes this is through formal housing programs, giving researchers potential access pre- and post- 3 examples from my work illustrate options: Regent Park housing redevelopment study Greater Toronto Area (GTA) West social housing & health study Manitoba linked housing and health database study

15 Regent Park Background home to 2,083 households & 7,500 people b/f demolition Phase 1 will grow from 418 to 800+ households Total: 5,100+ new units (2,083 RGI + 3,100 market) Right of return for existing residents one of Canada s oldest and largest public housing developments built in late 1940s / early 1950s based on Garden City design principles $1B+ demolition & redevelopment over next years in 6 phases. New community will: be mixed income: owners & subsidized renters use modern principles of urban design (new urbanism) implement social development plan

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17 Regent Park North and South

18 Regent Park Revitalization - Master Plan and Phasing

19 Phase One: Regent Park What it looks like Block 12 condominium Christian Resource Centre Condominium townhouses Sackville rental buildings Phase One rental townhouses Presentation centre One Cole condominium One Oak rental building 30 Regent Street rental townhouses

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21 Regent Park Housing and Health Study partnership b/w CRICH (SMH) and: Toronto Community Housing (TCHC) Regent Park Neighbourhood Initiatives (RPNI) Regent Park Community Health Centre (RP-CHC) Toronto Christian Resource Centre (TCRC) Canada Mortgage & Housing Corporation (CMHC) Ministry of Municipal Affairs and Housing (MMAH) tenants of Regent Park multidisciplinary research team geography, social epidemiology, child development, medicine, prospective cohort design, with comparison group collect baseline data from Phase 1 hholds (complete), Phase 2 hholds (complete) & comparison group Phase 1: n=60; Phase 2: n=150 comparison group: East downtown TCHC tenants

22 Study Objectives 1. to determine if adults (18+) who move from temporary housing to the new Phase 1 are significantly more likely than a comparison group to show improvements in depressive and anxious symptomatology (the common mental disorders ), and general health status; 2. to determine if children (ages 3-10) who move from temporary housing to the new Phase 1 are significantly more likely than a comparison group to show improvements in mental health, behavioural and developmental competencies;

23 Dependent Variables: Adults mental health problems are 2 nd leading cause of disability in affluent societies (WHO) common mental disorders are associated with impairments in physical and social functioning at least as severe as those associated with physical illness (Weich 1997, 757) combined community prevalence of 15-30% account for 1/3 of work days lost to illness and 1/5 of general practice consultations in the UK Center for Epidemiologic Studies Depression Scale (Revised Version) (CES-D-R) Beck 20-item anxiety scale (BAI) Short Form 8 item general health measure (SF-8)

24 Dependent Variables: Children 3-10 strengths and difficulties questionnaire brief behavioural screening instrument for children and youth, aged 3 to 16 years SDQ parent and teacher report 25 items five sub-scales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, prosocial behaviour

25 Regent Park Redevelopment Demolition and reconstruction of large public housing estate in downtown Toronto into mixed income, mixed land use community Study examines impact of redevelopment on adult mental health, many challenges What is the intervention? new housing, mixed income, temporary relocation, new neighbourhood? Selection, contamination of control and intervention groups, recruitment & retention, timing Potentially very powerful, but challenging

26 Potential Impact study will be the first of its kind in Canada a few similar studies exist in UK, most lack rigour study will inform subsequent Phases of redevelopment Study will inform future redevelopment Lawrence Heights 100+ sites in Canada? Will substantially improve our knowledge about the relationship between housing & health

27 GTA West Social Housing & Health Study Question: when people receive subsidized housing, does it improve mental health? Design: sample large group of people on wait list for housing, collect baseline data and wait Some people get housing, they become intervention Some people continue to wait, they become controls Housing wait list not a simple queue: selection priority status (e.g. Medical) a confounder Will be a study of households eligible for 2BR flats

28 Manitoba Linked Database Housing & Health Study Probabilistic linkage of social housing wait list / case files to health care utilization records Many possible studies of effect of housing on health E.g., select a cohort of people on wait list at Time A with mental health issues and follow impact of social housing vs. control group Main challenges: inflexibility of secondary data Determining the meaning of many variables is challenging Difficult to control for confounders Challenges offset somewhat by large sample sizes

29 Conclusion Great potential for natural experiments to inform public health interventions Especially important for health inequalities Helpful in filling very large knowledge gap Careful interpretation required, but advantages far outweigh disadvantages Many opportunities available, but requires more flexibility from funding agencies

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