Evaluating strategies for reducing health disparities by addressing the social determinants of health.
Open accessAbstract
The opportunities for healthy choices in homes, neighborhoods, schools, and workplaces can have decisive impacts on health. We review scientific evidence from promising interventions focused on the social determinants of health and discuss how such interventions can improve population health and reduce health disparities. We found sufficient evidence of successful outcomes to support disparity-reducing policy interventions targeted at education and early childhood; urban planning and community development; housing; income enhancements and supplements; and employment. Cost-effectiveness evaluations show that these interventions lead to long-term societal savings, but the interventions require more routine attention to cost considerations. We discuss challenges to implementation, including the need for long-term financing to scale up effective interventions for implementation at the local, state, and national levels.
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- Premisecitation
Early childhood programs yield substantial returns on investment.
“Additionally, there is strong and consistent empirical evidence that early childhood interventions, such as structured early childhood education and parental support programs, have positive health impacts on children and parents, show promise for addressing economic disadvantage and health disparities, and produce significant return on investment.(11, 12)”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Disadvantage exposure can cause harmful neurodevelopmental and biological effects from childhood onward, which build up and lead to disease.
“Exposure to disadvantage can have deleterious neurodevelopmental and biological consequences beginning in childhood that accumulate and produce disease.4”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] source
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- Premisecitation
Harlem Children's Zone erased the racial gap in math and English Language Arts seen at elementary school entry by third grade.
“Similarly the racial academic achievement gap in math and English Language Arts observed at enrollment in elementary school was eliminated by the third grade.(22)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [22] Dobbie W, 2011, American Econ J
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- Premisecitation
Estimated returns from early childhood education programs vary from $3 to $17 for each dollar spent.
“Return-on-investment estimates from these and other early childhood education programs range from returns of $3-$17 per dollar invested.(12)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [12] Karoly LA, 2005 source
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- Premisecitation
Many promising education interventions have not been evaluated for health effects.
“But many promising educational interventions have not been assessed for their impacts on health.(21)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [21] source
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- Premisecitation
Early childhood programs are promising for tackling economic disadvantage and health disparities.
“Additionally, there is strong and consistent empirical evidence that early childhood interventions, such as structured early childhood education and parental support programs, have positive health impacts on children and parents, show promise for addressing economic disadvantage and health disparities, and produce significant return on investment.(11, 12)”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Empirical evidence is strong and consistent that early childhood programs, including structured education and parent support, improve health for children and parents.
“Additionally, there is strong and consistent empirical evidence that early childhood interventions, such as structured early childhood education and parental support programs, have positive health impacts on children and parents, show promise for addressing economic disadvantage and health disparities, and produce significant return on investment.(11, 12)”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Better access to high-quality education probably leads to better health.
“Improving access to high-quality education likely improves health.(10)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [10] source
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- Interpretationcitation
Approaches focused on individuals and health systems cannot by themselves address social determinants like neighborhood conditions or poverty, which are basic causes of enduring disparities.
“However, these approaches are not sufficient to address social determinants such as neighborhood conditions or poverty, which are also fundamental drivers of persistent health disparities.3, 8”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Head Start evaluations have not consistently found positive health effects.
“Studies of the federally funded Head Start program, on the other hand, are not as promising, and show no consistent evidence of positive health impacts.(19)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [19]
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- Interpretationreasoning
Although each intervention reviewed mainly targets one social determinant, it probably affects other social determinants as well.
“Though the interventions we discuss in this article have a single social determinant as their primary target, the interventions are likely to have ripple effects across other social determinants.”
Quote in the paperNot a substantial claim - Premisecitation
Interventions targeting socioeconomic factors that drive disparities across several conditions are likely to yield the largest health gains.
“As Thomas Frieden’s 5-tiered Health Impact Pyramid suggests, the greatest health impact likely will come from interventions that address socioeconomic factors that drive health disparities across multiple conditions.(9)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [9] source
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- Premisecitation
The Nurse-Family Partnership produced an estimated long-term return of $18,054 per family, mostly through less crime, violence, child abuse, and other high-risk behavior.
“Another initiative, the Nurse-Family Partnership, an early childhood home visitation program targeting low-income first-time mothers, yielded an estimated $18,054 return per family over the long-term (18), largely from reductions in crime, violence, child abuse and other high-risk behaviors.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [18] Lee S, 2008, Evidence-based programs to prevent children from entering and remaining in the child welfare system: benefits and costs for Washington
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- Interpretationcitation
When a neighborhood is unsafe even in daytime and a person cannot afford to move somewhere safer, programs promoting outdoor exercise probably will not work.
“For example, if one’s neighborhood is unsafe even during daylight hours and an individual lacks the resources to move to a safer neighborhood, interventions targeting outdoor physical activity are unlikely to be effective.3”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] source
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- Premisecitation
Interventions in health systems that tackle discrimination, care access, and care quality matter.
“Health system interventions that address discrimination, access to care, and quality of care are also important (see the article by Tanjala Purnell and colleagues in this issue).(7)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [7] source
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- Premisecitation
In Harlem Children's Zone schools, the black-white math achievement gap disappeared over four years from middle school entry through ninth grade.
“For example, the schools in the Harlem Children’s Zone initiative, which combines rigorous education at a Promise Academy charter school with access to multiple community services for children living in a 97-block area in Harlem, eliminated the black-white academic achievement gap in math over the 4 years from enrollment in middle school to the completion of ninth grade.(22)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [22] Dobbie W, 2011, American Econ J
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- Premisecitation
A Michigan Head Start study found lower obesity rates among participants than among children who did not participate.
“A study of Head Start in Michigan, however, did find that participants had decreased obesity rates compared to non-participating children.(20)”
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- Premisecitation
Lead abatement programs have lowered childhood lead poisoning.
“For example, lead abatement and indoor air quality improvement interventions have reduced childhood lead poisoning and asthma morbidity, respectively.(35,36)”
Quote in the paperNot a substantial claim0 of 2 sources checked - Study design and conductreasoning
In such natural experiments, recipients and historical controls may differ systematically.
“meaning that systematic differences between intervention recipients and historic controls may exist”
Quote in the paperSubstantial claim - Interpretationreasoning
Early childhood intervention is the cheapest way to break the chain of events that raises children's risk of poor health in childhood and adulthood.
“While there remains a need for secondary prevention and treatment efforts for populations that are manifesting disparities in morbidity and mortality, intervening in early childhood is the most economical way to interrupt the cascade of events that puts children at increased risk of poor health outcomes in childhood and adulthood.”
Quote in the paperSubstantial claim - Interpretationcitation
Early childhood programs are cost-effective.
“In particular, early childhood interventions have demonstrated consistent effectiveness at improving long-term health outcomes for disadvantaged children and families, are associated with accrued health-related benefits into adulthood, and are cost effective.(12)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [12] Karoly LA, 2005 source
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- Premisecitation
Removing morbidity and mortality disparities for people without a college education would be worth an estimated $1.02 trillion.
“Eliminating disparities in morbidity and mortality for people with less than a college education would have an estimated economic value of $1.02 trillion.(53)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [53] 2014
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- Interpretationreasoning
Many reviewed interventions, especially in early childhood and housing and those with long-term follow-up and randomization, provide high-quality scientific evidence on health effects of social determinants interventions outside traditional health policy.
“Nevertheless, many interventions described – particularly in the early childhood and housing domains and those using long-term follow-up and randomization – represent high-quality scientific evidence of the health impacts of social determinants interventions that are far removed from traditional health policy.”
Quote in the paperSubstantial claim - Interpretationcitation
Early childhood programs have consistently improved long-term health outcomes for disadvantaged children and families.
“In particular, early childhood interventions have demonstrated consistent effectiveness at improving long-term health outcomes for disadvantaged children and families, are associated with accrued health-related benefits into adulthood, and are cost effective.(12)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [12] Karoly LA, 2005 source
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- Premisecitation
Improving indoor air quality has reduced asthma illness.
“For example, lead abatement and indoor air quality improvement interventions have reduced childhood lead poisoning and asthma morbidity, respectively.(35,36)”
Quote in the paperNot a substantial claim0 of 2 sources checked - Premisecitation
Supported Employment participation is linked to better employment outcomes for people with severe mental illness.
“Participation in Supported Employment, an evidence-based practice assisting people with severe mental illness to obtain and maintain employment, is associated with improved employment outcomes.(52)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [52] source
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- Premisecitation
WIC participation has been linked to lower low birth weight rates.
“WIC has been associated with reduced rates of low birth weight, and these effects appear stronger for women with lower versus higher education levels.(40)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [40] source
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- Premisecitation
The Five Plus Nuts and Beans trial suggests that combining grocery cash transfers with nutrition counseling for African Americans with controlled hypertension is linked to more fruit and vegetable intake and better diets.
“The Five Plus Nuts and Beans pragmatic randomized controlled trial conducted at the Johns Hopkins CPHHD Center suggests that pairing conditional cash transfers for use on groceries with nutritional counseling among African Americans with controlled hypertension is associated with increased fruit and vegetable consumption and improved dietary patterns.(45)”
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- Premisecitation
Natural experiments provide most of the evidence on how income support programs affect health.
“Most evidence assessing the impact of such programs on health comes from natural experiments.(8)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [8] source
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- Study design and conductown data
Several included studies used natural-experiment designs without random assignment to intervention versus control.
“Second, several of the studies were natural experiments that did not randomize participants to intervention or control groups”
Quote in the paperNot a substantial claim - Premisecitation
Housing and income supplement interventions have been linked to unanticipated negative health effects.
“This issue may be particularly important for optimizing housing and income supplement interventions because both have been associated with unanticipated negative health impacts.”
Quote in the paperSubstantial claim0 of 3 sources checked - Interpretationcitation
Conditional cash transfers may reduce disparities most when designed to benefit people with the lowest baseline incomes most.
“Conditional cash transfers may be most effective in reducing disparities when they are structured to have maximum impact for those with lower baseline incomes.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [44] source
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- Premisecitation
Some health benefits linked to the Earned Income Tax Credit, including better birth outcomes, may be larger for black people than white people.
“The same research suggests that some Earned Income Tax Credit-associated health benefits, such as improved birth outcomes, may be greater for blacks than whites.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [41] source
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- Premisecitation
The CDC Community Guide lists alcohol outlet density interventions as evidence-based for reducing alcohol use, abuse, and related morbidity.
“The Centers for Disease Control and Prevention Community Guide(30) touts interventions targeting alcohol outlet density as evidenced-based approaches for reducing alcohol use, abuse, and related morbidity.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [30] source
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- Study design and conductnone given
Most of the interventions reviewed lacked a priori design to evaluate health effects or disparities as such.
“First, most of the interventions discussed were not designed a priori to assess health impacts, or health disparities per se.”
Quote in the paperSubstantial claim - Premisecitation
Studies of employment interventions for vulnerable groups such as low-SES women and people with severe mental illness suggest these programs might reduce health disparities in those groups.
“Research examining employment interventions for specific vulnerable groups, including low socioeconomic status women and people with severe mental illness, also suggests that employment interventions could be effective in reducing health disparities in these populations.(50, 51)”
Quote in the paperSubstantial claim0 of 2 sources checked - Interpretationreasoning
Housing mobility programs aimed at giving low-income families access to economic opportunity and safer neighborhoods have shown possible health benefits.
“Though not originally designed to evaluate health outcomes, housing mobility programs that are intended to increase low-income families’ access to economic opportunity and safer neighborhoods have also demonstrated potential health impacts.”
Quote in the paperSubstantial claim - Interpretationcitation
Early childhood programs are linked to health-related benefits that accumulate into adulthood.
“In particular, early childhood interventions have demonstrated consistent effectiveness at improving long-term health outcomes for disadvantaged children and families, are associated with accrued health-related benefits into adulthood, and are cost effective.(12)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [12] Karoly LA, 2005 source
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- Study design and conductreasoning
Secular trend effects may have gone unmeasured in those natural experiments.
“and effects of secular trends may not have been measured.”
Quote in the paperNot a substantial claim - Premisecitation
Observational evidence is compelling that reducing alcohol outlet density and proximity lowers violent crime risk.
“Observational studies provide compelling evidence that decreasing the density of and proximity to alcohol outlets can reduce risk of violent crime(31), as well.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [31] source
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- Premisecitation
Strategies involving community engagement may be promising for reducing disparities.
“As the paper in this issue by Beti Thompson and colleagues discuss in detail, community-engaged strategies are potentially promising for ameliorating disparities.(25)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [25] source
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- Premisecitation
Low-income minority communities often have too many alcohol outlets.
“This has implications for reducing health disparities, as alcohol outlets are often over-concentrated in low-income minority communities.(29)”
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- Premisecitation
Philadelphia Healthy Food Financing Initiative research suggests that policies and programs improving healthy food access can raise residents' awareness of available options.
“Additionally, research from the Healthy Food Financing Initiative in Philadelphia suggests that policies and programs addressing access to healthy foods can increase awareness of viable options among residents.(27)”
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- Premisecitation
The link between WIC and lower low birth weight appears stronger among women with less education than among those with more.
“WIC has been associated with reduced rates of low birth weight, and these effects appear stronger for women with lower versus higher education levels.(40)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [40] source
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- Premisecitation
Income supplements were linked to higher adolescent obesity among low-income families.
“and in increased adolescent obesity among teens in low-income families.(57)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [57] source
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- Interpretationreasoning
A community development intervention that raises physical activity for all residents could widen disparities if advantaged groups increase activity more than disadvantaged groups.
“For example, a community development intervention that improves physical activity for all community residents could actually widen disparities if increases in physical activity are greater for advantaged versus disadvantaged groups.”
Quote in the paperNot a substantial claim - Interpretationreasoning
Individual program cost-effectiveness studies are insufficient to quantify the economic impact of social determinants interventions, which may have lifelong ripple effects across multiple domains.
“Individual program cost-effectiveness studies, although valuable, are insufficient to quantify the economic impact of social determinants interventions, which may have life-long ripple effects across multiple domains.”
Quote in the paperNot a substantial claim - Interpretationreasoning
Housing mobility interventions alone are not a viable stand-alone strategy for reducing health disparities because they leave health threats for those who cannot move.
“Further, housing mobility interventions by themselves are an untenable stand-alone strategy for addressing health disparities since they do not eliminate the threats to health that remain for those unable to move.”
Quote in the paperSubstantial claim- Rests on an assumption: It is not feasible to relocate all poor households.
- Rests on an assumption: Housing mobility interventions do not remove health threats for those who cannot move.
- Premisecitation
In a Moving to Opportunity sub-analysis, experimental-group assignment was linked to more mental health problems among boys.
“Similarly, in a sub-analysis of the Moving to Opportunity for Fair Housing Demonstration Project, assignment to the experimental group was associated with increased mental health problems among boys.(58)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [58] source
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- Premisecitation
In the Great Smoky Mountain Study, income supplements were linked to more accidental deaths and substance use during months when households received payments.
“For example, the income supplements received in the Great Smoky Mountain Study were also associated with increased accidental deaths and substance use in the specific months that households received payments,(56)”
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- Interpretationreasoning
Traditional health care sector-focused interventions are insufficient as a primary strategy for addressing population-level health disparities.
“Traditional health care sector-focused interventions are insufficient as a primary strategy to address population-level health disparities.”
Quote in the paperSubstantial claim
- Classified as probably not a substantial claim. 6
- May combine two claims. 26
Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
InterpretationreasoningMoving families to lower-poverty neighborhoods through affordable housing likely improves their access to better schools and neighborhood conditions.
“For example, an affordable housing intervention that moves families into lower poverty neighborhoods is likely to improve access to better educational opportunities and neighborhood conditions, as well.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationAdults who received the Perry Preschool intervention used safety belts more often and had lower rates of risky behaviors like smoking and illicit drug use.
“While the intervention was not designed to assess health impact, it did find that people receiving the intervention had higher rates of safety belt use and engaged in fewer risky health behaviors, such as smoking and illicit substance use in adulthood.(13)”
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PremisecitationIn their mid-30s, Abecedarian intervention participants had lower BMI and fewer cardiovascular and metabolic risk factors.
“By their mid-30’s, individuals in the intervention group had a lower body mass index and fewer risk factors for cardiovascular and metabolic disease.(15)”
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InterpretationcitationEarly childhood programs may improve health and narrow disparities by strengthening families, improving economic and educational outcomes, and preventing or interrupting harmful neurodevelopmental and biological effects of disadvantage.
“These programs can impact health and reduce disparities by strengthening families, improving economic outcomes, enhancing educational achievement, and acting to interrupt or prevent deleterious neurodevelopmental and biological consequences of disadvantage.4”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] source
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PremisecitationFor chronic conditions including obesity, cardiovascular disease, and cancer, health disparities continue and may be growing.
“Despite improvements in medical care and in disease prevention, health disparities persist and may be increasing for chronic conditions such as obesity, cardiovascular disease, and cancer.1, 2”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationA growing consensus holds that a life course perspective is among the most important ways to improve national health and is essential for reducing and eliminating population-level disparities.
“As such, there is a growing consensus that adopting a life course perspective, meaning focusing on how experiences early in life can impact health over a lifetime and even across generations, is one of the most important strategies to improve the nation’s health and is critical to reducing and eliminating population-level health disparities.3, 11”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
InterpretationreasoningInconsistent Head Start findings might result from differences in how sites implement the program and failure to follow a fixed curriculum.
“This may be because of variability in implementation across sites and lack of adherence to a set curriculum.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationBy age 40, Perry Preschool participants had lower rates of violent crime, imprisonment, welfare receipt, and births outside marriage.
“At age 40, those receiving the early childhood intervention had higher education, income and health insurance coverage and lower rates of violent crime, incarceration, welfare receipt and out of wedlock births. (14)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [14] Schweinhart LJ, 2005, Lifetime effects: the High/Scope Perry Preschool Study through age 40
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PremisecitationBy age 40, Perry Preschool participants had more education, higher income, and more health insurance coverage.
“At age 40, those receiving the early childhood intervention had higher education, income and health insurance coverage and lower rates of violent crime, incarceration, welfare receipt and out of wedlock births. (14)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [14] Schweinhart LJ, 2005, Lifetime effects: the High/Scope Perry Preschool Study through age 40
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PremisecitationAt 21, Abecedarian intervention participants had fewer depressive symptoms, less marijuana use, more physical activity, and better educational and vocational outcomes than controls.
“At age 21, the intervention group had fewer symptoms of depression, lower marijuana use, a more active lifestyle, and significant educational and vocational benefits compared to the control group.(16, 17)”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationPoverty, limited access to good education or jobs, poor housing, adverse work and neighborhood conditions, neighborhood violence, and concentrated disadvantage are social determinants that harm health.
“Social determinants that negatively impact health and wellbeing include poverty; lack of access to quality education or employment; unhealthy housing; unfavorable work and neighborhood conditions; exposure to neighborhood violence; and the clustering of disadvantage in particular groups of people and in particular places.3”
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PremisecitationAmong people with severe mental illness, employment improves quality of life, finances, and social support.
“For people with severe mental illness, employment improves quality of life, finances, and social support.(51)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [51] source
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PremisecitationCivil Rights policy research indicates that resulting employment and income gains raised life expectancy from the mid-1960s to mid-1970s more for blacks than whites and more for black women than black men.
“Research of the effects of Civil Rights policies, including equal access to employment and access to medical care, and enforcement of voting rights, indicates that the employment and income gains that resulted led to increases in life expectancy between the mid-1960s and the mid-1970s that were larger for blacks than whites, and greater for black women than black men.(49)”
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PremisecitationStudies in low- and middle-income countries suggest conditional cash transfers may raise preventive care use and improve nutrition, health behaviors, and birth outcomes.
“While less studied in high-income countries, research in low- and middle-income countries suggests that conditional cash transfers may be effective in increasing preventive health care utilization and improving nutrition, health behaviors, and birth outcomes, as well.(43)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [43] source
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PremisecitationIn the Yonkers Scattered-Site Public Housing Program, moving to middle-income neighborhoods was linked to better self-rated health, less substance use, more employment, and less neighborhood violence exposure.
“Moving to middle-income neighborhoods was associated with better self-reported health and decreased substance use, increased rates of employment, and decreased exposure to neighborhood violence.(37)”
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PremisecitationStarting the SSI program was linked to lower elderly mortality, with larger mortality declines as benefits rose.
“The initiation of the SSI program was associated with decreased mortality for the elderly and larger declines in mortality over time as benefit levels increased.(42)”
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PremisecitationThe Earned Income Tax Credit has been linked to lower low birth weight and less maternal smoking.
“The Earned Income Tax Credit has been associated with reductions in low birth weight and maternal smoking.(41)”
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PremisecitationMichigan's Project U-Turn was linked to more children walking to school and an estimated 63 percent citywide rise in active transportation.
“The project was associated with an increased proportion of children walking to school and an estimated 63 percent increase in active transportation citywide.(28)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [28]
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PremisecitationEliminating racial and ethnic disparities would cut medical care costs by $230 billion and indirect costs of excess illness and death by over $1 trillion over three years.
“Furthermore, research suggests that eliminating racial and ethnic disparities would reduce medical care costs by $230 billion and indirect costs of excess morbidity and mortality by more than $1 trillion over three years.(54)”
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InterpretationreasoningEnough evidence exists to support social determinant policy interventions in education and early childhood, urban planning and community development, housing, income supplements, and employment.
“As we have shown, there is sufficient evidence to support policy interventions that focus on the social determinants of health, including interventions targeted at education and early childhood, urban planning and community development, housing, income enhancements and supplements, and employment.”
Quote in the paperSubstantial claim- Rests on an assumption: The studies summarized in the article provide major and representative findings on social determinants likely to affect health and disparities.
- Rests on an assumption: There is limited population-level research on health impacts of employment interventions.
May combine two claims.
PremisecitationIn a study of women receiving TANF support, public health nursing case management was linked to more workforce entry, more preventive care use, and less depression.
“In one study among women receiving financial support from the Temporary Assistance for Needy Families program, public health nursing case management was associated with increased entrance into the workforce, increased preventive health care utilization, and improved depression.(50)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [50] source
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Study design and conductreasoningBecause of the long interval between intervention and health outcome measurement, especially in early childhood studies, unmeasured factors distinguishing intervention and control groups may explain observed outcomes.
“Finally, given the long lag-time between the intervention and measurement of health outcomes (particularly for early childhood studies), it is possible that other unmeasured factors that differentiate intervention and control groups are responsible for observed outcomes.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationChanging the distribution and density of alcohol outlets in low-income areas can affect substance abuse morbidity, crime, and neighborhood safety.
“In addition, interventions addressing distribution and density of alcohol outlets in low-income communities can impact substance abuse related morbidity, crime, and neighborhood safety.(29)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [29] source
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PremisecitationMore than ten years later, assignment to the Moving to Opportunity experimental group was linked to lower risk of extreme obesity and diabetes, more physical activity, and better mental health and wellbeing.
“Randomization to the experimental group was associated, more than a decade later, with decreased risk of extreme obesity and diabetes and increased physical activity, and improved mental health and wellbeing, for the study population.(38,39)”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationResearch indicates urban planning and community development can change community nutrition, physical activity, and safety, and may improve health behaviors.
“Studies have found that changes in nutrition, physical activity, and safety within communities can be achieved through urban planning and community development, which may also improve health behaviors.(24)”
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InterpretationreasoningScaling up these interventions will likely require government investment and social welfare reforms, including universal high-quality early childhood education, affordable housing matching demand, and housing mobility paired with neighborhood revitalization.
“Effective implementation will likely require government investment and social welfare reforms, such as universal access to high quality early childhood education programs, access to affordable housing that is commensurate with demand, and efforts to increase housing mobility that are coupled with effective strategies for revitalizing neighborhoods.”
Quote in the paperNot a substantial claim- Rests on an assumption: Lack of political will is an obstacle to scaling up these interventions.
- Rests on an assumption: Lack of access to long-term financing is an obstacle to scaling up these interventions.
- Rests on an assumption: Maintaining intervention quality during scale-up is an obstacle.
May combine two claims.
PremisecitationEmployment can affect health both positively and negatively through resources, chronic stress, and political power.
“Employment can have positive and negative impacts on health via effects on resources, chronic stress, and political power.(48)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [48] source
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InterpretationreasoningTo achieve sustained intergenerational health benefits, social determinant-related interventions must be paired with social marketing, behavioral economics, social services, and other supports.
“In order for such interventions to have sustained, intergenerational positive health impacts, they must be coupled with attention to social marketing, behavioral economics, social services, and other supports.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningHealth impacts of social determinant-focused interventions cannot be understood from randomized controlled trials alone; RCTs are not the only source of valuable scientific information.
“Furthermore, understanding the impacts of social determinant-focused interventions on health cannot come solely from randomized controlled trials.”
- Also stated in: § Discussion · plain
“While randomized controlled trials may be the gold standard for research, these are not the only source of generating valuable scientific information.”
Quote in the paperSubstantial claim- Also stated in: § Discussion · plain
Classified as probably not a substantial claim.
Interpretationnone givenThe complex individual-, family-, and community-level factors producing persistent health disparities cannot be reversed by short-term investments.
“The complex interplay of individual-, family-, and community-level factors impacting health that has resulted in persistent health disparities cannot be reversed with short-term investments.”
Quote in the paperSubstantial claim
The paper relies on this without support.
Current intervention strategies to reduce health disparities generally do not adopt a life-course perspective and are often disease-specific, targeting individual and health system factors without addressing social determinants.
“Yet, current intervention strategies to reduce health disparities do not typically take a “life-course perspective” and tend to be disease-specific, often targeting individual and health systems factors without addressing social determinants.”
The paper relies on this without support.
The studies summarized in the article provide major and representative findings on social determinants likely to affect health and disparities.
“The studies summarized in this article provide major and representative findings regarding the social determinants that are likely to impact health and health disparities.”
The paper relies on this without support.
There is limited population-level research on health impacts of employment interventions.
“There is limited population-level research examining health impacts of employment interventions.”
The paper relies on this without support.
It is not feasible to relocate all poor households.
“It also is not feasible to move all poor households.”
The paper relies on this without support.
Housing mobility interventions do not remove health threats for those who cannot move.
“since they do not eliminate the threats to health that remain for those unable to move.”
The paper relies on this without support.
Lack of political will is an obstacle to scaling up these interventions.
“Many obstacles remain, including lack of political will and access to long-term financing for these interventions”
The paper relies on this without support.
Lack of access to long-term financing is an obstacle to scaling up these interventions.
“Many obstacles remain, including lack of political will and access to long-term financing for these interventions”
The paper relies on this without support.
Maintaining intervention quality during scale-up is an obstacle.
“and threats to maintaining the high quality of interventions when scaling-up (for instance, insuring that early childhood education programs maintain their rigor and standardization when broadly disseminated).”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Social determinants of health can have profound effects on patients' health, particularly on older patients that have disproportionately accumulated these effects over the life course (the 'Weathering' effect).
“These determinants can have profound effects on patients’ health, particularly on older patients that have disproportionately accumulated these effects over the life course (the “Weathering” effect) [73–75].”
From Bias in medical AI: Implications for clinical decision-making (2024) · cites this paper as [74]
The citation lists haven’t been fetched yet
References 56 · Cited by 591
Research works printed but not linked: 3
- Lee S, 2008, Evidence-based programs to prevent children from entering and remaining in the child welfare system: benefits and costs for Washington
- Dobbie W, 2011, American Econ J, 3, 158
- 2014, Time to act: investing in the health of our children and communities
- Authors
- Thornton, R. L. J., Glover, C. M., Cené, C. W., Glik, D. C., Henderson, J. A., & Williams, D. R.
- Affiliations
- Johns Hopkins University (US)
- BMO (United States) (US)
- University of North Carolina at Chapel Hill (US)
- University of California, Los Angeles (US)
- Black Hills Center for American Indian Health (US)
- Harvard University (US)
- ORCID
- Venue
- Health Affairs
- Publisher
- Health Affairs Publishing, LLC
- Published
- 2016-08
- Volume
- 35
- Issue
- 8
- Pages
- 1416-1423
- ISSN
- 0278-2715 (ISSN-L)
- 1544-5208
- PMC
- PMC5524193
- OpenAlex
- W2496601852
- Cited by
- 591
- References
- 56
- Citations by year
- 2026: 39 · 2025: 88 · 2024: 84 · 2023: 89 · 2022: 69 · 2021: 89 · 2020: 54 · 2019: 31 · 2018: 27 · 2017: 15 · 2016: 4
- FWCI
- 33.91
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Health Affairs (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- UNC Libraries
- Funders
- National Institutes of Health (5p50ca148110-05, 1p50hl105188-01)
- National Heart, Lung, and Blood Institute (P50HL105187, P50HL105184, P50-HL105188, K23HL121250, P50HL105185, P50HL105189)
- National Cancer Institute (U54CA153498, P50CA106743, P50CA148596, #P50CA148110, P50CA148143, P50CA105632)
- National Institute on Minority Health and Health Disparities
- Topics
- Social Sciences › Health › Health disparities and outcomes
- Social Sciences › Health › Public Health and Social Inequalities
- Health Sciences › Health Professions › General Health Professions › Public Health Policies and Education
- Keywords
- health disparities, social determinants of health, health policy interventions, early childhood education, urban planning, community development, housing, additional income, employment, cost-effectiveness, implementation barriers, population health
- MeSH terms
- Child Health, Female, Health Planning, Health Policy, Health Promotion, Humans, Male, Policy Making, Public Health, United States, Risk Assessment, Health Status Disparities, Healthcare Disparities, Social Determinants of Health
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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