Welcome back. Still the last week, Week 7. This is Part 2 of 3.

We're still talking about doing things from a social epidemiologic perspective. In this module, I want to talk about one of the things social epidemiologists think about a lot or have thought about a lot. And that is changing neighborhood environments in order to improve population health. It's the broad topic, sometimes called neighborhood effects and it's garnered a lot of attention for over ten years from social epidemiologists. And so, I thought a module today on doing things with neighborhood effects was critical to our course. So, the idea here is, how much, how do we know how much one's neighborhood, affects their health? And the best way to assess this, of course, would be to randomize a bunch of people to different neighborhoods, good and bad. And then, see over time, perhaps over 50 years, how their health was different. This is obviously a challenge. So, in this discussion I want to talk about what's been done in social epidemiology to get at that desired counter factual. One of the things we want to do is say, how do we change the neighborhood environment in which people live to help them be more healthy. May be its fruit stands, may be its more opportunities for exercise, more safety, better neighbours, all kinds of things can be imagined. You want to assess how much of an impact these neighbourhood changes have on health. As I said in our last lecture, if we can't demonstrate an impact, we haven't really done our job for policy makers. Well, there's two broad types of neighborhood effect, or neighborhood studies I want to discuss here. The first is, change the environment itself, and then leave the people who are there, in place. So this is about coming into the neighborhood and changing something. It might be making a park better. It might be better police. It might be remove some toxins. The idea is to keep the people where

they're living and change that neighborhood itself. The other approach is the opposite. The opposite side of the same coin, if you will. And this is to take people from a given neighborhood. And move them to a better neighborhood, move them out. And then, what we'd want to do is move people out at random. And we'll talk about this in the second half of this module. Well, by way of example, the first kind of study has been done it's a very extensive undertaking. And in the 1980s the United States National Institutes of Health. Particularly the National Heart, Lung, and Blood Institute, sort of funded or initiated three very large field experiments, where the idea was to improve the heart health or cardiovascular health of residents of various neighborhoods. Now, the idea scientifically was to see how much of an impact this heart health intervention had. So, there was a research design where neighborhoods, whole neighborhoods, were randomized or put into the treatment group or the comparison/control group. And this was done in three big studies. and each study had a whole number of neighborhoods. The three big studies that are usually talked about are first, the Part, Paw, Pawtucket Heart Health Program, and that's in Pawtucket, Rhode Island. And so, the city of Pawtucket received an intervention which I'll talk about, compared to a never-to-be-disclosed comparison city. Next was the Stanford, Stanford, California, 5-city project. And the idea was the same. Five cities got some health improvement for heart health, and then five comparison cities did not. The last, of course, is the Minnesota Heart Health Study which sort of put University of Minnesota epidemiology on the map. And the idea was the same here. Intervene our heart health in some areas, and compare them to others. Let's think about how this works. So, in terms of intervention, you could read a lot about this. But the short story is, health promoters,

health educators, went into these various treatment neighborhoods. And try to do things such as educate the population on what it means to have a healthy heart. More exercise, better diets, don't smoke, watch alcohol. They also did mass media campaigns. They had TV shows. Sort of mini-commercials, if you will. Often at late at night due to the cost of these things. And then last, there was training of physicians of the doctors on how to educate and work with their own patients to improve heart health. So, this is a multi-disciplinary, multi-level intervention in the target neighborhoods to improve cardiovascular or heart health. What wasn't done was nothing in the comparison cities. They were just left to be. And then, over time the question was how did the heart health of the treatment neighborhoods compare to those of the non-treatment or comparison neighborhoods. For the Minnesota Heart Health Program, three intervention communities were compared to three control communities. This affected about 400,000 people in the state of Minnesota, a very large field study. Results. Results for all these studies were somewhat disappointing. Of course, the devil's always in the detail. But by and large, these interventions in the neighbors did not the produce, did not produce the results researchers were hoping they would. Heart health professionals were disappointed as well. Why did that occur? Two big reasons, one we learn that the statistical designs, the research designs that I spoke of in earlier lectures, were not sufficient to detect these effects. In short, we didn't have enough neighborhoods randomized to create, to treatment or control. These days we understand these statistical issues better. But second, and this is an interesting problem, there was a secular or historical trend going on. So that the persons living in the comparison or control neighborhoods were

also just naturally, improving their heart health. So, that meant that the treatment communities not only had to, do something, but do something more, than what was already occurring. So, by in large when we look back historically, these very expensive, very important, neighborhood interventions did not to produce, did not produce the results we were hoping for. But there are some methodological reasons why. So, it's not accurate to say there was no effect. It's better to say no effect was discernible or detectable. The second kind of study that we described earlier in this lecture is also interesting. In this case what we want to do is move people out of their neighborhoods into, presumably, better or healthier neighborhoods. The great example of this is what's called the Moving to Opportunity study. Again, another US study. Here, the idea was to take people in impoverished areas who are on, to be simple, government-subsidized housing. And to give them a chance, they could volunteer, no one had to do this, to move to a better neighborhood. So, the short story of the study is, find volunteers in public or government-subsidized housing in poor areas. Ask them to volunteer. Of those who volunteer, randomize, approximately half. It's a little more complicated, but approximately half, to a voucher, and assistance to move to a better place. And then, those who didn't get that, were the so-called control group and they didn't have to move. The could stay where they are, or they could move as they normally would in a regular life. This was done in five cities in America. And within each city, persons are randomized to a better place, this voucher program or not. And again, I'm simplifying the study. This affected about 4,600 persons who were in the study at large. And the idea again was to first see if the people who moved actually moved to so-called better places, less impoverished places.

Now, technically there were three arms to the study. It wasn't just treatment control. It was treatment, which was you got a voucher and you got assistance to find a new place. Or you just got a voucher and you had to find your own place yourself, or you got nothing. Sort of standard of care, if you will. Now, one of the important things about this study is it was not originally designed as a health study. In fact, it was designed by the Department of Housing and Urban Development to see if the researchers could show that living in a better neighborhood increase one's chance for better employment. It was a jobs study originally and the health researchers came after. The results. Well, first we learned that people who did move, in fact, did move to better places. Not dramatically better, because remember these are relatively impoverished persons. And there's not a lot of subsidised housing in very wealthy neighbourhoods. It's one of those social facts we've talked about earlier in the course. The study show that there was little impact on one's chances for employment or great increase in educational and educational attainment. So, here we have a study designed, originally designed to improve jobs and educational attainment for jobs, but neither of those effects, effects was demonstrated. The people in the moving group were about the same as the people in the comparison group. When it comes to health, the health reachers, health researchers came in later for the study, they did some, find some effects. People in the better neighborhoods reported better mental health and things, but it was also complicated. Some health measures, did not improve as much as we wanted to. Others didn't improve at all. So by enlarge I think the answer on the health improvement, is that the results were ambiguous. One of the things to note about, asking people to move to, to a new neighborhood. Is that approximately only 47% of those

who could move actually did. The question is why not, and this is a fascinating question for social epidemiology. Do they not want to move? Did they not think they could move? Well, researchers have looked into it, and the basic problem was there's simply not enough housing available. At least, easily accessible for those living in deep poverty. There's no place to go. So, this is part of the social system that we talked about. The social system is not setup so that persons in poor areas can actually find a better place in wealthier or less impoverished areas. So, quite a part from the treatment effect estimates how much this change or not. One of the things we learned was, well, it's actually hard to find housing for the deeply impoverished. We also learned that the places where people wanted to move did not want those people moving in. This is the not in my back yard or NIMBY phenomenon. And we see this with toxic dumps and other kinds of things that people don't want in the wealthier neighborhoods. Again, this is part of the social system and key to understanding social epidemiology. Final, we learned that many persons who didn't move to a better place actually moved back. Why would they do this? Well, there's lots of reasons perhaps, but from a social epi perspective, it's probably because they knew the original place. They had social support, it might be child care, they might know the bus system. So, if you think about it from their perspective, it's not an irrational thing to go back home if you will.