Effect of Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder on Criminality

OBJECTIVE

Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes.

METHOD

We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference.

RESULTS

Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges.

CONCLUSION

This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning.

STUDY PREREGISTRATION INFORMATION

The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.

A diverse portfolio of marine protected areas can better advance global conservation and equity

Marine protected areas (MPAs) are widely used for ocean conservation, yet the relative impacts of various types of MPAs are poorly understood. We estimated impacts on fish biomass from no-take and multiple-use (fished) MPAs, employing a rigorous matched counterfactual design with a global dataset of >14,000 surveys in and around 216 MPAs. Both no-take and multiple-use MPAs generated positive conservation outcomes relative to no protection (58.2% and 12.6% fish biomass increases, respectively), with smaller estimated differences between the two MPA types when controlling for additional confounding factors (8.3% increase). Relative performance depended on context and management: no-take MPAs performed better in areas of high human pressure but similar to multiple-use in remote locations. Multiple-use MPA performance was low in high-pressure areas but improved significantly with better management, producing similar outcomes to no-take MPAs when adequately staffed and appropriate use regulations were applied. For priority conservation areas where no-take restrictions are not possible or ethical, our findings show that a portfolio of well-designed and well-managed multiple-use MPAs represents a viable and potentially equitable pathway to advance local and global conservation.

The effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease

AIMS

To assess the effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

A few recent studies have shown that unsupervised home-based pulmonary rehabilitation can improve the clinical outcome of patients with COPD. More studies are needed to prove its benefits.

DESIGN

This study used a quasi-experimental design.

METHODS

Seventy-two admitted COPD patients were assigned to experimental group or control group through purposeful sampling. Data were collected from March 2016 to November 2017 in the Thoracic Intensive Care Unit of a Medical Center in Taiwan. The Medical Research Council dyspnea scale, the COPD Self-Efficacy Scale and the Clinical COPD Questionnaire were measured before education and at the first, second and third months after discharge.

RESULTS

The Medical Research Council dyspnea scale and COPD Self-Efficacy Scale results in the experimental group were significantly improved compared with the control group in the third month after discharge. The Clinical COPD Questionnaire score continued to improve in both groups in the third month after discharge, and there was no difference between the two groups.

CONCLUSION

A short-term unsupervised home-based pulmonary rehabilitation with self- management program had significant benefits for patients with COPD. The long-term effects need to be confirmed.

Emergency communications after earthquake reveal social network backbone of important ties

Social networks provide a basis for collective resilience to disasters. Combining the quasi-experimental context of a major earthquake in Ya'an, China, with anonymized mobile telecommunications records regarding 91,839 Ya'an residents, we use initial bursts of postdisaster communications (e.g. choice of alter, order of calls, and latency) to reveal the "important ties" that form the social network backbone. We find that only 26.8% of important ties activated during the earthquake were the strongest ties during normal times. Many important ties were hitherto latent and weak, only to become persistent and strong after the earthquake. We show that which ties activated during a sudden disaster are best predicted by the interaction of embeddedness and tie strength. Moreover, a backbone of important ties alone (without the inclusion of weak ties ordinarily seen as important to bridge communities) is sufficient to generate a hierarchical structure of social networks that connect a disaster zone's disparate communities.

The effect on women's health of extending parental leave: a quasi-experimental registry-based cohort study

BACKGROUND

Parental leave policies have been hypothesized to benefit mothers' mental health. We assessed the impact of a 6-week extension of parental leave in Denmark on maternal mental health.

METHODS

We linked individual-level data from Danish national registries on maternal sociodemographic characteristics and psychiatric diagnoses. A regression discontinuity design was applied to study the increase in parental leave duration after 26 March 1984. We included women who had given birth between 1 January 1981 and 31 December 1987. Our outcome was a first psychiatric diagnosis following the child's birth, ascertained as the first day of inpatient hospital admission for any psychiatric disorder. We presented cumulative incidences for the 30-year follow-up period and reported absolute risk differences between women eligible for the reform vs not, in 5-year intervals.

RESULTS

In all, 291 152 women were followed up until 2017, death, emigration or date of first psychiatric diagnosis. The median follow-up time was 29.99 years, corresponding to 10 277 547 person-years at risk. The cumulative incidence of psychiatric diagnoses at 30 years of follow-up was 59.5 (95% CI: 57.4 to 61.6) per 1000 women in the ineligible group and 57.5 (95% CI: 55.6 to 59.4) in the eligible group. Eligible women took on average 32.85 additional days of parental leave (95% CI: 29.20 to 36.49) and had a lower probability of having a psychiatric diagnosis within 5 years [risk difference (RD): 2.4 fewer diagnoses per 1000 women, 95% CI: 1.5 to 3.2] and up to 20 years after the birth (RD: 2.3, 95% CI: 0.4 to 4.2). In subgroup analyses, the risk reduction was concentrated among low-educated, low-income and single women.

CONCLUSIONS

Longer parental leave may confer mental health benefits to women, in particular to those from disadvantaged backgrounds.

The challenge of dementia prevention trials and the role of quasi-experimental studies

Observational studies have shown consistently that modifiable risk factors during life are associated with increased dementia risk in old age but randomized controlled trials (RCTs) on dementia prevention evaluating the treatment of these risk factors did not find consistent effects on cognitive outcomes. The discrepancy in findings is potentially attributable to inherent differences between the two study designs. Although RCTs are the gold standard for establishing causality, designing and conducting an RCT for dementia prevention is complex. Quasi-experimental studies (QESs) may contribute to investigating causality without randomization. QESs use variation in exposure to a risk factor or intervention in an observational setting to deduct causal effects. Design-specific approaches are used to control for confounding, the main caveat of QESs. In this article we address the challenges, opportunities, and limitations of QESs for research into dementia prevention. HIGHLIGHTS: Despite consistent associations between modifiable risk factors and dementia, the mostly neutral effects of randomized controlled trials (RCTs) challenge the causality of these associations. RCTs in the field of dementia prevention are often problematic due to ethical, practical, or financial constraints, and their results may have limited generalizability. Four quasi-experimental study (QES) designs may be suitable to study causality between risk factors and dementia; we critically appraise these study designs for dementia-prevention studies. We describe how specific QES designs can be used to study the effects of risk-factor modification for 12 known risk factors for dementia.

Dynamic Changes in Drinking Behaviour among Subpopulations of Youth during the COVID-19 Pandemic: A Prospective Cohort Study

OBJECTIVE

Youth drinking is highly heterogenous, and subpopulations representing different alcohol use patterns may have responded differently to the COVID-19 pandemic. This study examined changing patterns of alcohol use in subpopulations of the youth population over the first two years of the pandemic.

METHOD

We used linked survey data from 5367 Canadian secondary school students who participated in three consecutive waves of the COMPASS study between 2018/19 and 2020/21. Latent transition analysis (LTA) was used to identify patterns of alcohol use based on the frequency of drinking and frequency of binge drinking and to estimate the probability of transitioning between identified patterns.

RESULTS

LTA identified five patterns of alcohol use each representing a unique subpopulation: abstainer, occasional drinker-no binging, occasional binge drinker, monthly binge drinker, weekly binge drinker. Probability of being engaged in binge drinking for a subpopulation of occasional drinkers pre-pandemic was 61%, which reduced to 43% during the early-pandemic period. A lower proportion of occasional binge drinkers reported moving to monthly or weekly binge drinking. Female occasional drinkers were more likely to move to binge drinking patterns during the pandemic than males.

CONCLUSIONS

Less frequent drinking and younger students were more likely to reduce their drinking and binge drinking than more established drinkers during the COVID-19 pandemic. Understanding of heterogenous patterns of alcohol drinking and different responses to public health crises may inform future preventive programs tailored to target subpopulations more effectively.

Weathering the storm together: Does unemployment insurance help couples avoid divorce?

This study examines whether unemployment insurance benefit generosity impacts divorce, drawing on full population administrative data and a Swiss reform that reduced unemployment insurance maximum benefit duration. We assess the effect of the reform by comparing the pre- to the post-reform change in divorce rates among unemployed individuals who were affected by the reform with the change in divorce rates among a statistically balanced group of unemployed individuals who was not affected by the reform. Difference-in-differences estimates suggest that the reform caused a 2.8 percentage point increase in divorce (a 25% increase). Effects were concentrated among low-income couples (+58%) and couples with an unemployed husband (+32%) though gender differences are attributable to men's breadwinner status. Female main breadwinners were more strongly affected (+78%) than male main breadwinners (+40%). Results confirm the 'family stress model' which posits that job search and financial stress cause marital conflict. Policymakers should consider a broad array of impacts, including divorce, when considering reductions in unemployment insurance generosity.

Co-use of cannabis and alcohol before and after Canada legalized nonmedical cannabis: A repeat cross-sectional study

BACKGROUND

This study examined changes in population-level co-use of cannabis and alcohol before and 12 months after nonmedical cannabis legalization in Canada, relative to the United States that had previously legalized and not legalized (US legal and illegal states, respectively).

METHODS

Data are from waves 1 and 2 of the International Cannabis Policy Study, collected in 2018 (before) and 2019 (12 months after legalization in Canada). Respondents aged 16-65 years from Canada (n = 25,313) and US legal (n = 25,189) and US illegal (n = 19,626) states completed an online survey. Changes in co-use between 2018 and 2019 in US legal and illegal states compared to those in Canada were assessed using multinomial logistic regression.

RESULTS

Descriptive analyses show increases in cannabis use and monthly or more frequent (MMF) co-use between 2018 and 2019 in all jurisdictions. Compared to no MMF use of cannabis or alcohol, there was no evidence suggesting differences in changes in MMF co-use in US legal or illegal states relative to Canada. However, respondents in US legal states had 33% higher odds of MMF alcohol-only use (OR = 1.33, 99% CI: 1.12, 1.57) compared to no MMF use relative to Canada.

CONCLUSIONS

Increases in co-use were observed between 2018 and 2019 in all jurisdictions regardless of the legal status of cannabis. These shifts were largely due to increases in cannabis use across the population, including those that use alcohol, and may indicate changing societal norms toward cannabis generally. As the cannabis legalization transition in Canada matures, evaluation over the longer term will improve understanding of the influence of cannabis liberalization on co-use.

Estimating the Effectiveness of First Dose of COVID-19 Vaccine Against Mortality in England: A Quasi-Experimental Study

Estimating real-world vaccine effectiveness is vital to assessing the coronavirus disease 2019 (COVID-19) vaccination program and informing the ongoing policy response. However, estimating vaccine effectiveness using observational data is inherently challenging because of the nonrandomized design and potential for unmeasured confounding. We used a regression discontinuity design to estimate vaccine effectiveness against COVID-19 mortality in England using the fact that people aged 80 years or older were prioritized for the vaccine rollout. The prioritization led to a large discrepancy in vaccination rates among people aged 80-84 years compared with those aged 75-79 at the beginning of the vaccination campaign. We found a corresponding difference in COVID-19 mortality but not in non-COVID-19 mortality, suggesting that our approach appropriately addressed the issue of unmeasured confounding factors. Our results suggest that the first vaccine dose reduced the risk of COVID-19 death by 52.6% (95% confidence limits: 15.7, 73.4) in those aged 80 years, supporting existing evidence that a first dose of a COVID-19 vaccine had a strong protective effect against COVID-19 mortality in older adults. The regression discontinuity model's estimate of vaccine effectiveness is only slightly lower than those of previously published studies using different methods, suggesting that these estimates are unlikely to be substantially affected by unmeasured confounding factors.

Changing contexts: A quasi-experiment examining adolescent delinquency and the transition to high school

In a quasi-experiment, we examine whether changing schools during the transition from 8th to 9th grade influences adolescent delinquency, using a sample of more than 14,000 students in 26 public school districts (PROSPER study). The dataset follows students for eight waves from 6th through 12th grade and facilitates a unique, direct comparison of students who change schools with those who remain in the same school during this period. Results show that students who transition between schools report significantly less delinquency after the shift than those who do not, and that this difference persists through 10th grade. This decline is most pronounced when adolescents from multiple middle schools move to a single high school (i.e., multifeeder transitions). Students who transition between schools have fewer delinquent friends and participate in less unstructured socializing following the change in school environment, which partially mediates their reduced delinquency. Results provide some support for theories of differential association and routine activities. Our findings highlight the role of a crucial, yet understudied, life transition in shaping adolescent delinquency. The results from this quasi-experiment underscore the potential of alterations in social context to significantly dampen juvenile delinquency throughout high school.

Working life expectancy and working years lost among users of part- and full-time sickness absence in Finland

OBJECTIVES

The use of part-time sickness absence (pSA) instead of full-time sickness absence (fSA) is known to increase work participation. Yet, its effect on the total length of working lives remains unclear. We carried out a quasi-experiment to assess the impact of using pSA versus fSA on the length of working lives.

METHODS

We used a register-based 70% random sample of the working-age population living in Finland on 31 December 2007 to (i) form propensity-score-matched groups of users of pSA and fSA and (ii) calculate their working life expectancy (WLE) and working years lost (WYL). We applied the Sullivan method based on daily measured time spent at work and other labor market statuses, followed up over a four-year period until the end of year 2017. The study population consisted of private and public sector employees with SA due to mental and musculoskeletal disorders, ie, the diagnostic groups where pSA has been primarily used.

RESULTS

Among both genders, the pSA group had a significantly higher WLE at age 30 than the fSA group, with larger differences seen in mental disorders compared to musculoskeletal diseases and in the private versus public sector. Overall, the pSA group had fewer WYL due to unemployment and disability retirement but more expected years working with partial disability benefits than the fSA group.

CONCLUSIONS

Based on beneficial working career effects, the use of pSA instead of fSA should always be recommended for persons with mental or musculoskeletal disorders where feasible.

Least Squares and Robust Rank-Based Double Bootstrap Analyses for Time-Series Intervention Designs

Time-series intervention designs that include two or more phases have been widely discussed in the healthcare literature for many years. A convenient model for the analysis of these designs has a linear model part (to measure changes in level and trend) plus a second part that measures the random error structure; the error structure is assumed to follow an autoregressive time-series process. Traditional generalized linear model approaches widely used to estimate this model are less than satisfactory because they tend to provide substantially biased intervention tests and confidence intervals. We describe an updated version of the original double bootstrap approach that was developed by McKnight et al. (2000) to correct for this problem. This updated analysis and a new robust version were recently implemented in an R package (McKean & Zhang, 2018). The robust method is insensitive to outliers and problems associated with common departures from normality in the error distribution. Monte Carlo studies as well as published data are used to demonstrate the properties of both versions. The R code required to perform the analyses is provided and illustrated.

Developing Metacognition of 5- to 6-Year-Old Children: Evaluating the Effect of a Circling Curriculum Based on Anji Play

Metacognition plays an important role in young children's learning and daily life activities. Based on Anji Play, we designed a metacognition enhancement program named Circling Curriculum for Metacognition Training (CCMT). With a quasi-experimental design, we examined the effects of the CCMT program on the metacognition of 5-6 year old Chinese children. Two classes of 5-6 year old children were randomly assigned into an experimental group (n = 25, 10 girls, mean age = 65.92 months, SD = 3.58) and a control group (n = 22, 10 girls, mean age = 66.77, SD = 3.87). The experimental group received the three-month CCMT, while the control group received routine teaching activities without imposing any interventions. All children took the metacognition test before and after the intervention. Results indicated that (1) there was no significant difference between the experimental group and the control group in all dimensions of metacognitive ability in the pre-test; (2) the experimental group exhibited better metacognitive ability than the control group in most dimensions of metacognitive ability in the post-test; and (3) the gain scores in the metacognitive ability of experimental group were significantly higher than those of the control group. The results are very encouraging and suggest that CCMT can foster the development of the metacognitive ability of young children.

The impact of vocational rehabilitation on employment outcomes: A regression discontinuity approach

OBJECTIVES

Since 2015, Finnish disability pension applicants who are rejected or receive a short-term temporary pension have, under certain conditions, also received a preliminary decision for vocational rehabilitation (VR). A key requirement for eligibility is a certain amount of earnings during the previous five years (€34 910.29 in 2017). We exploit this discontinuity to examine the impact of assignment to VR on labor market outcomes.

METHODS

All new disability pension applicants from 2015 to 2017 were included. Fuzzy regression discontinuity design was used to evaluate the impact of assignment to VR on employment, unemployment and earned income two years later among those close to the threshold (+/- €20 000) providing eligibility for the preliminary decision. Arguably, those just below and just above the earnings limit are similar to each other, allowing causal interpretation of the estimates.

RESULTS

For each of the employment outcomes, we found a modest effect in the expected direction at the income threshold, but there is considerable uncertainty in these findings. On average, exceeding the income limit increased the probability of employment by 7.6 percentage points, but the estimate was far from statistical significance. Unemployment became slightly less common and earned income slightly increased, but the estimates were also clearly statistically non-significant.

CONCLUSIONS

We found no consistent evidence of the impact of assignment to VR on employment outcomes among low-income disability pension applicants. However, given the narrow and specific study population, this should not be taken as evidence of ineffectiveness of VR more generally.

Impact of Parental Beliefs on Child Developmental Outcomes: A Quasi-Experiment in Rural China

This paper examines the impact of parental beliefs on child development outcomes (for both cognitive and social−emotional skills) based on a three-wave longitudinal survey in rural China. The survey waves were conducted when the sample children were 18−30 months, 22−36 months, and 49−65 months, respectively. A total of 815 children and their primary caregivers who participated in all three wave surveys were enrolled in this study. Using difference-in-differences and propensity score matching approaches, the results indicate that strengthened parental beliefs have a positive and significant impact on child social−emotional development. Specifically, between the periods of the Wave 1 survey (when children were 18−30 months old) and the Wave 3 survey (when children were 49−65 months old), and between the Wave 2 survey (when children were 22−36 months old) and the Wave 3 survey, strengthened parental beliefs were causally associated with more favorable child social−emotional scores by 0.44 SD (p < 0.01) and 0.49 SD (p < 0.01), respectively. No significant impact, however, was found between the period of the Wave 1 survey and the Wave 2 survey. In contrast, weakened parental beliefs had a negative and significant impact on child social−emotional development. Specifically, weakened parental beliefs were causally associated with worse child social−emotional abilities by 0.35 SD (p < 0.01), 0.30 SD (p < 0.01), and 0.22 (p < 0.05) for the time period of the Wave 1 to Wave 2, Wave 1 to Wave 3, and Wave 2 to Wave 3, respectively. No significant impact of parental beliefs, however, was found on child cognitive development. In addition, the findings of the mediation analysis show that only a marginal impact of parental beliefs on child social−emotional development can be indirectly explained by parental beliefs through parenting practices. This study calls on policy makers to improve parental beliefs and parenting practices in the hope that it will lead to better child development in rural China.

The Effectiveness of the Capacity Building and Mentorship Program in Improving Evidence-Based Decision-making in the Amhara Region, Northwest Ethiopia: Difference-in-Differences Study

Background

Weak health information systems (HISs) hobble countries’ abilities to effectively manage and distribute their resources to match the burden of disease. The Capacity Building and Mentorship Program (CBMP) was implemented in select districts of the Amhara region of Ethiopia to improve HIS performance; however, evidence about the effectiveness of the intervention was meager.

Objective

This study aimed to determine the effectiveness of routine health information use for evidence-based decision-making among health facility and department heads in the Amhara region, Northwest Ethiopia.

Methods

The study was conducted in 10 districts of the Amhara region: five were in the intervention group and five were in the comparison group. We employed a quasi-experimental study design in the form of a pretest-posttest comparison group. Data were collected from June to July 2020 from the heads of departments and facilities in 36 intervention and 43 comparison facilities. The sample size was calculated using the double population formula, and we recruited 172 participants from each group. We applied a difference-in-differences analysis approach to determine the effectiveness of the intervention. Heterogeneity of program effect among subgroups was assessed using a triple differences method (ie, difference-in-difference-in-differences [DIDID] method). Thus, the β coefficients, 95% CIs, and P values were calculated for each parameter, and we determined that the program was effective if the interaction term was significant at P<.05.

Results

Data were collected using the endpoint survey from 155 out of 172 (90.1%) participants in the intervention group and 166 out of 172 (96.5%) participants in the comparison group. The average level of information use for the comparison group was 37.3% (95% CI 31.1%-43.6%) at baseline and 43.7% (95% CI 37.9%-49.5%) at study endpoint. The average level of information use for the intervention group was 52.2% (95% CI 46.2%-58.3%) at baseline and 75.8% (95% CI 71.6%-80.0%) at study endpoint. The study indicated that the net program change over time was 17% (95% CI 5%-28%; P=.003). The subgroup analysis also indicated that location showed significant program effect heterogeneity, with a DIDID estimate equal to 0.16 (95% CI 0.026-0.29; P=.02). However, sex, age, educational level, salary, and experience did not show significant heterogeneity in program effect, with DIDID estimates of 0.046 (95% CI –0.089 to 0.182), –0.002 (95% CI –0.015 to 0.009), –0.055 (95% CI –0.190 to 0.079), –1.63 (95% CI –5.22 to 1.95), and –0.006 (95% CI –0.017 to 0.005), respectively.

Conclusions

The CBMP was effective at enhancing the capacity of study participants in using the routine HIS for decision-making. We noted that urban facilities had benefited more than their counterparts. The intervention has been shown to produce positive outcomes and should be scaled up to be used in other districts. Moreover, the mentorship modalities for rural facilities should be redesigned to maximize the benefits.

Trial Registration

Pan African Clinical Trials Registry PACTR202001559723931; https://tinyurl.com/3j7e5ka5

How to Use Artificial Intelligence to Improve Entrepreneurial Attitude in Business Simulation Games: Implications From a Quasi-Experiment

Business simulation games (BSGs) have been widely used in entrepreneurship education with positive effects. However, there are still some deficiencies in the BSGs, such as limited guidance, low uncertainty and limited simulation environment, which make it impossible to exert the maximum effect. Artificial intelligence (AI) can solve the above shortcomings. The combination of AI and BSGs is the possible development direction of BSGs. But how to effectively combine BSGs with AI is still an open question. Using a quasi-experimental design, this study uses fuzzy-set qualitative comparative analysis to analyze how participants' entrepreneurial attitude changes in BSGs. The results show that BSGs can effectively improve entrepreneurial attitude, and there are four types of promotion configurations. These four configurations consist of five antecedent conditions. According to the above conclusions, AI can improve entrepreneurial attitude in BSGs in various ways, such as simulating competitors, providing targeted feedback for failures, and improving game experience. The contribution of this paper is to highlight the possibility of combining AI with BSGs, and to provide suggestions on how AI can intervene in BSGs.

Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax

BACKGROUND

Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases.

OBJECTIVES

We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax.

METHODS

A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore.

RESULTS

Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54).

CONCLUSIONS

In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

Consider This Before Using the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic as an Instrumental Variable in an Epidemiologic Study

Epidemiologists sometimes use external sources of variation to explore highly-confounded exposure-outcome relationships or exposures that cannot be randomized. These exogenous sources of variation, or natural experiments, are sometimes proposed as instrumental variables to examine the effects of a given exposure(s) on a given outcome(s). Previous epidemiological studies have applied this technique using famines, earthquakes, weather events, and previous pandemics as exogenous sources of variation for other exposures; interest in applying this technique using the current severe acute respiratory system coronavirus 2 (SARS-CoV-2) pandemic is already documented. Yet, large-scale events like these likely have broad and complicated impacts on human health, which almost certainly violates the exclusion restriction assumption of instrumental variable analyses. We review the assumptions of instrumental variable analyses, highlight previous applications of this method with respect to natural experiments with broad impacts or “shocks”, and discuss how these relate to our current observations of the SARS-CoV-2 pandemic. While we encourage thorough investigation of the broad impacts of the SARS-CoV-2 pandemic on human health, we caution against its widespread use as an instrumental variable to study other exposures of interest.

Rejoice architecture meets social norms to accelerate vaccination in Nepal: Protocol for a mixed-method quasi-experimental study

Background: Each year, 600,000 children under 5 years old die from vaccine-preventable diseases globally. Immunization is an effective way to prevent many diseases, saving two to three million lives per year. The Nepal National Government recommends vaccinations for all children for 11 diseases by 15 months of age. However, only 78% of children between 1-2 years of age have received all recommended vaccines and only 43% receive them at the age-appropriate times for which they are scheduled. Objectives: This protocol describes the development of an intervention - called "Rejoice Architecture" - that is informed by three theoretical perspectives: choice architecture, the broken windows theory, and the theory of normative social behavior. We also describe a mixed-methods approach to develop the intervention, which will improve the physical and social environments of health facilities in Makwanpur, Nepal. We hypothesize this intervention will improve immunization behaviors and intentions among mothers of children younger than 2 years, pregnant women, and prospective mothers. Methods: We describe the qualitative formative assessment to understand existing attitudes, norms, and behaviors among caregivers, healthcare workers, and government representatives. The formative assessment will include in-depth interviews, key informant interviews, and focus group discussions. We also describe the overall quasi-experimental study design, used to assess intervention impact. Impact: This study will contribute to the social and behavioral change communication intervention research by offering a novel strategy for increasing immunization. This study will also illustrate to policymakers the value of structural change for health service delivery.

Protocol for an evaluation of the Designing Communities to Support Healthy Living in Aging Residents Study

BACKGROUND

In collaboration with building developers, the Housing for Health team is contributing to the design of community-based congregate living facilities to support healthy living in older adults. There may also be opportunities to improve the surrounding neighbourhoods by collaborating with the municipalities where the developments are located. We will evaluate whether one or more of these comprehensive interventions lead to changes in the perceived, microscale, and macroscale neighbourhood-built environment (BE) and amenities, and impacts on the physical activity (PA), healthy eating, and social connections of residents. In parallel, we will gather qualitative data to provide a more in-depth understanding of how the BE may facilitate or hinder resident's healthy living outcomes.

METHODS

This project employs a quasi-experimental pre-post design with at least one or more intervention and control sites. The quantitative BE evaluation will include pre- and post-intervention assessments of neighbourhood macroscale (e.g., layout of communities) and microscale (e.g., street details and characteristics) changes using Geographical Information Systems (GIS) and Microscale Audit Pedestrian Streetscapes (MAPS) audits, respectively. The quantitative resident evaluation will include self-report (i.e., surveys) and objective assessments (i.e., accelerometers, Global Positioning System [GPS]) of residents at baseline (3-6-months pre-move-in) and follow-up (3-6-months and 9-12-months post-move-in if possible). The qualitative resident-environment component will involve in-depth semi-structured interviews post-intervention with building residents, family members, and stakeholders involved in the design/development and/or operation of the intervention site(s). Participant observations will be completed in the building and neighbourhood environments of the intervention site(s).

DISCUSSION

Findings will provide evidence on whether and how comprehensive changes to the BE and amenities of at least one congregate living facility and the surrounding neighbourhood can impact PA, healthy eating, and social connections of older adults. Successful intervention elements will be scaled up in future work. We will disseminate findings to a broad audience including the scientific community via peer-reviewed publications, conference presentations, and discussion panels; and the private, public, and not-for-profit sectors via reports, public presentations, and/or communications via our partners and their networks.

TRIAL REGISTRATION

Protocol ID: 1819-HQ-000051. ClinicalTrials.gov ID: NCT05031273. Registered 29 June 2021 with ClinicalTrials.gov.

Differential impact of on-site or telepharmacy in the intensive care unit: a controlled before-after study

BACKGROUND

Clinical pharmacists have an important role in the intensive care unit (ICU) team but are scarce resources. Our aim was to evaluate the impact of on-site pharmacists on medical prescriptions in the ICU.

METHODS

This is a retrospective, quasi-experimental, controlled before-after study in two ICUs. Interventions by pharmacists were evaluated in phase 1 (February to November 2016) and phase 2 (February to May 2017) in ICU A (intervention) and ICU B (control). In phase 1, both ICUs had a telepharmacy service in which medical prescriptions were evaluated and interventions were made remotely. In phase 2, an on-site pharmacist was implemented in ICU A, but not in ICU B. We compared the number of interventions that were accepted in phase 1 versus phase 2.

RESULTS

During the study period, 8797/9603 (91.6%) prescriptions were evaluated, and 935 (10.6%) needed intervention. In phase 2, there was an increase in the proportion of interventions that were accepted by the physician in comparison to phase 1 (93.9% versus 76.8%, P < 0.001) in ICU A, but there was no change in ICU B (75.2% versus 73.9%, P = 0.845).

CONCLUSION

An on-site pharmacist in the ICU was associated with an increase in the proportion of interventions that were accepted by physicians.

Will high-speed railway influence the healthcare seeking behaviour of patients? Quasi-experimental evidence from China

This study examines the impacts of high-speed railway (HSR) transportation on the healthcare-seeking behaviour of patients along newly integrated areas of Sichuan province, China. The opening of the Cheng-Mian-Le intercity HSR is considered as quasi-experimental evidence from China, and we make a propensity score matching the difference in differences research design, using data from the monthly report database of the Sichuan Province health statistical data collection and Decision Support System from 2014 to 2015. We find that, first, the opening of the HSR resulted in significant healthcare-seeking behaviour with great heterogeneity. Second, patients are more likely to go to areas with high-density healthcare resources, in which case HSR may mitigate the diagnostic inaccuracies that patients face locally. Third, the 'distance enhancement effect' was present, and its marginal effect is more significant for long-distance patients. Fourth, the tiered-network healthcare policy has no significant restrictive impact on patients seeking high-level medical services. Our results show that HSR establishment has a substantial impact on the behaviour of people seeking medical treatment and medicine. Furthermore, we discuss the results' policy implications for the allocation and integration of China's healthcare market, and the accessibility of medical and health services.

Impact of Teacher's Mental State Talk on Young Children's Theory of Mind: A Quasi-Experiment Study

This study investigated the relationship between teachers' mental state talk and young children's theory of mind with a quasi-experiment. In total, 56 young children were assigned to the experiment group (mean_age = 41 months, SD = 2.47, 46% girls) and the control group (mean_age = 40.68 months, SD = 2.23, 43% girls). The experiment group was engaged in a 12-week intervention program with mental state talk in storytelling, casual conversations, and role-playing games, whereas the control group received no interventions. All the children were tested with three theory of mind (ToM) tasks before and after the intervention. The results indicated that the experimental group had a significant improvement in the ToM scores, whereas the control group showed no significant change. The educational implications of these findings are discussed.

Matching methods to quantify wildfire effects on forest carbon mass in the U.S. Pacific Northwest

Forest wildfires consume and redistribute carbon within forest carbon pools. Because the incidence of wildfires is unpredictable, quantifying wildfire effects is challenging due to the lack of prefire data or controls from experiments over a large landscape. We explored a quasi-experimental method, propensity score matching, to estimate wildfire effects on aboveground forest woody carbon mass in Washington and Oregon, United States. Observational data, including national forest inventory plot measurements and satellite imagery metrics, were utilized to obtain a control set of unburned plots that are comparable to burned plots in terms of environmental conditions as well as spatial locations. Three matching methods were implemented: propensity score matching (PSM), spatial matching (SM), and distance-adjusted propensity score matching (DAPSM). We investigated if propensity score matching with and without spatial adjustment led to different outcomes in terms of (1) balance in covariate distributions between burned and control plots, (2) mean carbon mass obtained from the selected control plots compared to burned and all unburned plots, and (3) estimates of wildfire effects by burn severity. We found that PSM and SM, which use only the environmental covariate set or the spatial distance for estimating propensity scores, respectively, did not appear to produce a comparable set of control plots in terms of the estimated propensity scores and the outcomes of mean carbon mass. DAPSM was the preferred method both in balancing the observed covariates and in dealing with unobservable confounding variables through spatial adjustment. The average wildfire effects estimated by DAPSM showed clear evidence of redistribution of carbon among aboveground woody pools, from live to dead trees, but the consumption of total woody carbon by wildfire was not substantial. Only moderate burn severity led to significant reduction of total woody carbon mass across Washington and Oregon forests (64% of control plots remained on average). This study provides an applied example of a quasi-experimental approach to quantify the effects of a natural disturbance for which experimental settings are unavailable. The study results suggest that incorporating spatial information in addition to environmental covariates would yield a comparable set of control plots for wildfire effects quantification.

The Effect of a Tailored Intervention on Female Soccer Players' Hydration Status

Numerous studies have reported that athletes' pre-training/-game hydration status is of concern. Up to now, only two cohort studies have examined the effect of an intervention aimed at improving pretraining/-game hydration status; however, without including a control group. Therefore, the aim of this quasi-experimental study was to examine whether and to what extent an individually tailored intervention focused on the benefits of being optimally hydrated before training or game would alter the hydration status of female soccer players. Two teams of young adult female soccer players were allocated to an intervention (n = 22; 19.8 ± 3.0 years) or a control group (n = 15; 22.8 ± 4.0 years). Players in the intervention group received an individually tailored intervention, based on Urine Specific Gravity (USG) measurements, which took place in between two training weeks. Before each training and match play, a urine sample was collected to determine players' hydration status. Mixed modelling was applied to assess within and between differences in hydration status over time. The pre-training/-game hydration status of the intervention group improved significantly, with players' mean USG-value decreasing from 1.013 ± 0.001 g/mL to 1.008 ± 0.002 g/mL (p = 0.005). In contrast, the mean USG-value in the control group increased significantly from 1.012 ± 0.002 g/mL to 1.016 ± 0.002 g/mL (p = 0.023), indicating a deterioration of their pre-training/-game hydration status. The individually tailored intervention did show a positive effect even though female soccer players in the present study were already reasonably well hydrated before the start of the intervention.

"Yes We Can!" The Mental Health Significance for U.S. Black Adults of Barack Obama's 2008 Presidential Election

This study examines the mental health significance of Barack Obama's 2008 presidential election for black adults. His election was a milestone moment. Hence, we expect black adults would experience improved mental health after the first self-identified black person wins election to the most powerful position in the United States. Using nationally representative survey data from the Behavioral Risk Factor Surveillance System (BRFSS), we address this expectation by predicting poor mental health days that black adults report pre-election and post-election. We find no overall difference in poor mental health days between the time periods. However, a statistical interaction between gender and time period demonstrates black men report 1.01 fewer poor mental health days after the election, whereas black women report .45 more poor mental health days after the election.

A quasi-experimental study into the effects of naps and therapy glasses on fatigue and well-being

Aim

To investigate the effects of a napping facility and therapy glasses on fatigue and well‐being at the end of the night shift.

Background

Night shift work has adverse effects on fatigue and well‐being.

Methods

A quasi‐experimental study was conducted, and data were collected on 243 night shifts of 95 nurses who had either access to a napping facility, therapy glasses, both facilities or no facilities. Multilevel analyses were conducted to predict fatigue and well‐being.

Results

Night shifts of nurses having access to both facilities were associated with less fatigue and more well‐being. The use of therapy glasses related negatively to fatigue and positively to well‐being. The use of the napping facility was not associated with fatigue and well‐being. However, having slept while napping and sleeping time during napping were negatively associated with fatigue and positively associated with well‐being.

Conclusion

Therapy glasses and sleeping in a napping facility can be effective interventions in reducing the adverse effects of night shift work.

Implications for Nursing Management

Therapy glasses seem an effective investment to facilitate the well‐being of nurses. To enhance sleeping during napping, it is worthwhile to let nurses get accustomed to the napping facility and customize settings to personal preferences.

Combined infant and young child feeding with small-quantity lipid-based nutrient supplementation is associated with a reduction in anemia but no changes in anthropometric status of young children from Katanga Province of the Democratic Republic of Congo: a quasi-experimental effectiveness study

BACKGROUND

Small-quantity lipid-based nutrient supplements (SQ-LNS) are efficacious in controlled settings; data are scarce on the effectiveness utilizing health care delivery platforms.

OBJECTIVE

We evaluated the impact of an infant young child feeding (IYCF)-SQ-LNS intervention on anemia and growth in children aged 6-18 mo in the Democratic Republic of Congo following a quasi-experimental effectiveness design.

METHODS

An intervention health zone (HZ) received enhanced IYCF including improved counseling on IYCF during pregnancy until 12 mo after birth and daily use of SQ-LNS for infants 6-12 mo; the control HZ received the standard IYCF package. We analyzed data from 2995 children, collected in repeated cross-sectional surveys. We used adjusted difference-in-difference analyses to calculate changes in anemia, iron and vitamin A deficiencies, stunting, wasting, and underweight.

RESULTS

Of mothers, 70.5% received SQ-LNS at least once in the intervention HZ, with 99.6% of their children consuming SQ-LNS at least once. The mean number of batches of SQ-LNS (28 sachets per batch, 6 batches total) received was 2.3 ± 0.8 (i.e., 64.4 ± 22.4 d of SQ-LNS). The enhanced program was associated with an 11.0% point (95% CI: -18.1, -3.8; P < 0.01) adjusted relative reduction in anemia prevalence and a mean +0.26-g/dL (95% CI: 0.04, 0.48; P = 0.02) increase in hemoglobin but no effect on anthropometry or iron or vitamin A deficiencies. At endline in the intervention HZ, children aged 8-13 mo who received ≥3 monthly SQ-LNS batch distributions had higher anthropometry z scores [length-for-age z score (LAZ): +0.40, P = 0.04; weight-for-age z score (WAZ): +0.37, P = 0.04] and hemoglobin (+0.65 g/dL, P = 0.007) and a lower adjusted prevalence difference of stunting (-16.7%, P = 0.03) compared with those who received none.

CONCLUSIONS

The enhanced IYCF-SQ-LNS intervention using the existing health care delivery platform was associated with a reduction in prevalence of anemia and improvement in mean hemoglobin. At endline among the subpopulation receiving ≥3 mo of SQ-LNS, their LAZ, WAZ, and hemoglobin improved. Future research could explore contextual tools to maximize coverage and intake adherence in programs using SQ-LNS.

Rejoice architecture meets social norms to accelerate vaccination in Nepal: Protocol for a mixed-method quasi-experimental study

Background: Each year, 600,000 children under 5 years old die from vaccine-preventable diseases globally. Immunization is an effective way to prevent many diseases, saving two to three million lives per year. The Nepal National Government recommends vaccinations for all children for 11 diseases by 15 months of age. However, only 78% of children between 1-2 years of age have received all recommended vaccines and only 43% receive them at the age-appropriate times for which they are scheduled. Objectives: This protocol describes the development of an intervention - called "Rejoice Architecture" - that is informed by three theoretical perspectives: choice architecture, the broken windows theory, and the theory of normative social behavior. We also describe a mixed-methods approach to develop the intervention, which will improve the physical and social environments of health facilities in Makwanpur, Nepal. We hypothesize this intervention will improve immunization behaviors and intentions among mothers of children younger than 2 years, pregnant women, and prospective mothers. Methods: We describe the qualitative formative assessment to understand existing attitudes, norms, and behaviors among caregivers, healthcare workers, and government representatives. The formative assessment will include in-depth interviews, key informant interviews, and focus group discussions. We also describe the overall quasi-experimental study design, used to assess intervention impact. Impact: This study will contribute to the social and behavioral change communication intervention research by offering a novel strategy for increasing immunization. This study will also illustrate to policymakers the value of structural change for health service delivery.

Crying Therapy Intervention for Breast Cancer Survivors: Development and Effects

BACKGROUND

crying therapy is currently being applied in some countries to treat cancer patients, manage pain, and promote mental health. However, little nursing and medical research on the effects of crying therapy has been conducted in other parts of the world. This study aimed to develop a crying therapy program for breast cancer survivors and assess its effects. Interventions/method: data from 27 breast cancer survivors in South Korea were analyzed. The intervention, employing a single group, pre-post-test quasi-experimental design, was divided into three phases, and effects were verified for emotional (distress, fatigue, and mood conditions) and physiological (cortisol, immunoglobulin G, and blood pressure) variables.

RESULTS

there were significant changes in distress, mood changes, and immunoglobulin G and smaller changes in blood pressure postintervention. Fatigue and cortisol showed no significant changes.

CONCLUSIONS

this study demonstrated the effectiveness of a short-term crying therapy program that can induce positive emotional changes and physiological effects in breast cancer survivors. This intervention can improve quality of life, indicating its value as a self-care program for cancer survivors.

Income dividends and subjective survival in a Cherokee Indian cohort: a quasi-experiment

Persons with high temporal discounting tend to value immediate gratification over future gains. Low self-reported lifespan (SRL)-an individual's assessment of a relatively short future lifespan-concentrates in low-income populations and may reflect high temporal discounting. We use casino-based cash dividends among the Eastern Band of Cherokee Indians (EBCI) as a quasi-experiment to test whether large income gains among EBCI members translate into increased SRL. We used SRL data for EBCI and White youth, aged 19 to 28, participating in two waves of the Life Time Trajectory of Youth (LTI-Y) survey from 2000 to 2010. We controlled for unobserved confounding across individuals, time, and region through a longitudinal design using a difference-in-difference analytic approach (N = 294). We conducted all analyses separately by gender and by quartile of socioeconomic status. Cash dividends correspond with a 15.23 year increase in SRL among EBCI men below the lowest socio-economic quartile at baseline relative to Whites (standard error = 5.39, p < .01). Results using other socio-economic cut-points support improved SRL among EBCI men (but not women). The large magnitude of this result among EBCI men indicates that a non-trivial cash dividend to a low-income population may confer long-term benefits on perceptions of future lifespan and, in turn, reduce temporal discounting.Abbreviations: EBCI: Eastern Band of Cherokee Indians; SES: Socioeconomic Status; LTI-Y: Life Trajectory Interview for Youth; GSMS: Great Smoky Mountains Study; SRL: Self-Reported Lifespan; SSS: Subjective Social Status.

Effects of a School Based Intervention on Children's Physical Activity and Healthy Eating: A Mixed-Methods Study

Combined diet and physical activity school-based interventions (rather than only diet or physical activity interventions) are more likely to help prevent children from becoming overweight in the long term. However, such interventions are less prevalent, and therefore, this pilot study aimed to assess the feasibility of a gardening intervention coupled with awareness about plant-based meals among 9−10 year old children in a London primary school. We recruited 60 children from two Year 5 classes, one class participated as an intervention group, and results were compared against another class who acted as the control group. Children’s physical activity (PA) was measured using GENEActiv wrist-worn accelerometers. Their fruit and vegetable intake and attitudes to and preferences in eating fruits and vegetables were measured using a self-report questionnaire. Furthermore, three focus groups were held with children in the intervention group to understand the reasons behind any change as a result of the intervention. Results are inconclusive; however, they indicate some impact on reduction of sedentary behaviour, increase of moderate to vigorous PA, knowledge of nutrition and some level of acceptance in trying new vegetables. School-based interventions involving gardening show some promise to increase children’s PA and improve their attitudes to eating fruits and vegetables.

The Use of a Quasi-Experimental Study on the Mortality Effect of a Heat Wave Warning System in Korea

Many cities and countries have implemented heat wave warning systems to combat the health effects of extreme heat. Little is known about whether these systems actually reduce heat-related morbidity and mortality. We examined the effectiveness of heat wave alerts and health plans in reducing the mortality risk of heat waves in Korea by utilizing the discrepancy between the alerts and the monitored temperature. A difference-in-differences analysis combined with propensity score weighting was used. Mortality, weather monitoring, and heat wave alert announcement data were collected for 7 major cities during 2009–2014. Results showed evidence of risk reduction among people aged 19–64 without education (−0.144 deaths/1,000,000 people, 95% CI: −0.227, −0.061) and children aged 0–19 (−0.555 deaths/1,000,000 people, 95% CI: −0.993, −0.117). Decreased cardiovascular and respiratory mortality was found in several subgroups including single persons, widowed people, blue-collar workers, people with no education or the highest level of education (university or higher). No evidence was found for decreased all-cause mortality in the population (1.687 deaths/1,000,000 people per day; 95% CI: 1.118, 2.255). In conclusion, heat wave alerts may reduce mortality for several causes and subpopulations of age and socio-economic status. Further work needs to examine the pathways through which the alerts impact subpopulations differently.

Modeling lottery incentives for daily adherence

Many health issues require adherence to recommended daily activities, such as taking medication to manage a chronic condition, walking a certain distance to promote weight loss, or measuring weights to assess fluid balance in heart failure. The cost of nonadherence can be high, with respect to both individual health outcomes and the healthcare system. Incentivizing adherence to daily activities can promote better health in patients and populations and potentially provide long‐term cost savings.

Multiple incentive structures are possible. We focus here on a daily lottery incentive in which payment occurs when both the participant's lottery number matches the number drawn and the participant adheres to the targeted daily behavior.

Our objective is to model the lottery's effect on participants' probability to complete the targeted task, particularly over the short term. We combine two procedures for analyzing such binary time series: a parameter‐driven regression model with an autocorrelated latent process and a comparative interrupted time series. We use the output of the regression model as the control generator for the comparative time series in order to create a quasi‐experimental design.

A Sharing-Based Approach to Enticing Tourists to Behave More Environmentally Friendly

Tourist behavior has a critical impact on the environmental sustainability of tourism. The hedonic nature of tourism and lack of an economic incentive make tourist behavior particularly hard to change. Making tourists behave more environmentally friendly would have substantial environmental benefits. This is the aim of the present study. Three alternative approaches are tested. The most successful approach-based on sharing monetary savings with guests-leads to a 42 percent change in one specific tourist behavior with negative environmental consequences. This new sharing-based approach significantly outperforms current approaches of increasing awareness of environmental consequences and of tourist ability to make a change. Tourism businesses should consider replacing current appeals with sharing-based schemes.

Effects of state education requirements for substance use prevention

We provide the first evidence on the effects of state laws requiring students to receive education about alcohol, tobacco, and other drugs using data on over a million youths from the 1976-2010 Monitoring the Future study. In difference-in-differences and event-study models, we find robust evidence that these laws significantly reduced recent alcohol and marijuana use among high school seniors by 1.6-2.8 percentage points, or about 8-10% of the overall decline over this period. Our results suggest that information interventions can reduce youth substance use.

Optimal Allocation of Interviews to Baseline and Endline Surveys in Place-Based Randomized Trials and Quasi-Experiments

BACKGROUND

Many place-based randomized trials and quasi-experiments use a pair of cross-section surveys, rather than panel surveys, to estimate the average treatment effect of an intervention. In these studies, a random sample of individuals in each geographic cluster is selected for a baseline (preintervention) survey, and an independent random sample is selected for an endline (postintervention) survey.

OBJECTIVE

This design raises the question, given a fixed budget, how should a researcher allocate resources between the baseline and endline surveys to maximize the precision of the estimated average treatment effect?

RESULTS

We formalize this allocation problem and show that although the optimal share of interviews allocated to the baseline survey is always less than one-half, it is an increasing function of the total number of interviews per cluster, the cluster-level correlation between the baseline measure and the endline outcome, and the intracluster correlation coefficient. An example using multicountry survey data from Africa illustrates how the optimal allocation formulas can be combined with data to inform decisions at the planning stage. Another example uses data from a digital political advertising experiment in Texas to explore how precision would have varied with alternative allocations.

Association between Platescapes, Foodscapes, and Meal Energy Intake in Government Employees from Muar, Johor, Malaysia

A microscale built environment was the focus in this cross-sectional study which aimed to investigate the associations between platescapes, foodscapes, and meal energy intake among subjects. A total of 133 subjects (54 male, 79 female) with mean age 36.8 ± 7.3 years completed a self-administered questionnaire on sociodemographic characteristics, platescapes, and foodscape preferences. For platescapes, a plate mapping method was used, where subjects were required to place various sizes of food models on two different sized plates (23 cm and 28 cm) based on their preferences. For foodscape preferences, subjects were given a 23-cm plate and various food models differentiated by shapes and colours. Then, 24-h daily recalls (for one weekday and one weekend day) were obtained using interviews. Significant differences were observed in meal energy intake (p < 0.05) between males (1741 ± 339 kcal) and females (1625 ± 247 kcal) and also between age groups (p < 0.05). There was a significant difference (p < 0.0001) in terms of subjects’ meal energy intake when comparing 23-cm plates (419 ± 124 kcal) and 28-cm plates (561 ± 143 kcal). The bigger plate (28 cm) (p < 0.01) was significantly associated with subjects’ meal energy intakes, but this was not so for the 23-cm plate. There were significant differences in subjects’ meal energy when comparing white rice and multicoloured rice (p < 0.0001), unicoloured and multicoloured proteins (p < 0.0001), and unicoloured and multicoloured vegetables (p < 0.0001). There was a significant difference found between round- and cube-shaped proteins (p < 0.05). The colours of rice (p < 0.01), protein (p < 0.05), and vegetables (p < 0.05) were significantly associated with subjects’ meal energy. Only the shape of carrots in vegetables (p = 0.01) was significantly associated with subjects’ meal energy. Subconsciously, platescapes and foodscapes affect an individual’s energy intake, and thus these elements should be considered in assessing one’s dietary consumption.

Neighbourhood socioeconomic position and risks of major chronic diseases and all-cause mortality: a quasi-experimental study

OBJECTIVES

This study estimated the health impacts of neighbourhood socioeconomic position (SEP) among public housing residents. Because applicants to public housing were assigned to housing projects primarily based on factors other than personal choice, we capitalised on a quasirandom source of variation in neighbourhood of residence to obtain more valid estimates of the health impacts of neighbourhood SEP.

DESIGN

Quasiexperimental study.

SETTING

Greater Metropolitan Toronto area, Canada.

PARTICIPANTS

Residents (24 019-28 858 adults age ≥30 years in 1994 for all outcomes except for asthma, for which the sample was expanded to 66 627 individuals age ≥4 years) of public housing on 1 January 1994.

OUTCOME MEASURES

Incident hypertension, diabetes, asthma, and acute myocardial infarction (MI) and all-cause mortality between 1 January 1994 and 31 December 2006. We used multivariate Cox proportional hazards models to estimate hazard ratios (HRs) for the associations between the quartile of census tract-level SEP and the risk of diagnosis of each health outcome as well as death from any cause.

RESULTS

Living in a public housing project in the second highest neighbourhood SEP quartile (Q3) was associated with lower hazards of acute MI (HR=0.76, 95% CI 0.54 to 1.07; P=0.11), incident asthma (HR=0.80, 95% CI 0.67 to 0.96; P=0.02) and all-cause mortality (HR=0.86, 95% CI 0.73 to 1.01; P=0.06) compared to living in the lowest neighbourhood SEP quartile (Q1), although only the trend for incident asthma reached statistical significance (P for trend=0.04). By contrast, the associations corresponding to living in the highest versus lowest quartile of median household income (Q4 vs Q1) were neither consistent in direction nor significant. The inconsistent associations may partly be attributed to selection and status incongruity.

CONCLUSION

This study provides new evidence compatible with protective influences of higher neighbourhood SEP on health outcomes, particularly asthma.

Cognitive and emotional outcomes after prolonged education: a quasi-experiment on 320 182 Swedish boys

Background: Cognitive and socio-emotional abilities are powerful predictors of death and disease as well as of social and economic outcomes. Education is societies’ main way of promoting these abilities, ideally so that inequalities by socioeconomic background are reduced. However, the extent to which education serves these cognitive, social-emotional and equality objectives is relatively unknown and intensively debated. Drawing on a Swedish school reform that was explicitly designed as a massive quasi-experiment, we assessed differential impact of education on intelligence and emotional control across childhood socioeconomic position. We also assessed initial differences in abilities by childhood socioeconomic position and how well childhood socioeconomic position and abilities predict all-cause mortality.

Methods: The Swedish comprehensive school reform, rolled out during the 1950s, extended compulsory education from 8 to 9 years in some municipalities whereas others were kept as controls for the sake of evaluation. We followed eight full cohorts of Swedish boys born between 1951 and 1958, who lived in 1017 municipalities with known experimental status (344 336 boys) and whose childhood socioeconomic position was known (320 182 boys). At conscription, intelligence was measured by four subtests and emotional control (calm and efficient responses in various situations) was rated by a military psychologist. Both measures were standardized to have a mean of 100 and standard deviation of 15. All-cause mortality was recorded until 49–56 years of age.

Results: The reform had an average positive impact on intelligence of 0.75 IQ units (95% confidence interval (CI): 0.54, 0.97; P < 0.0005). The impact on emotional control was negative; −0.50 units (95% CI: −0.72, −0.28; P < 0.0005). Both effects differed by socioeconomic background so that the average IQ difference between sons of high non-manual and unqualified manual workers was reduced from 16.32 to 15.57 units and the difference in emotional control was reduced from 6.50 to 5.63 units. All-cause mortality was predicted by low childhood socioeconomic position [hazard ratio (HR) = 1.15 [95% CI: 1.11, 1.20], P < 0.0005], low intelligence [HR = 1.39 (95% CI: 1.34, 1.44), P < 0.0005] as well as low emotional control [HR = 1.61 (95% CI: 1.55, 1.67), P < 0.0005] in mutually adjusted models.

Conclusions: Extending compulsory education promoted intelligence but lowered emotional control, and reduced disparities over social background in both. Emotional control was the strongest predictor of all-cause mortality. Our results are in line with the idea that education is important in our efforts to achieve healthy, competent and fair societies, but much more work is needed to understand the links between education and non-cognitive skills.

Effectiveness of a working memory intervention program in children with language disorders

The aim of this study was twofold: first, to obtain a neuropsychological characterization of children with language disorders, and second, to evaluate the effectiveness of an intervention program on working memory. We used a pretest-instruction-posttest design, carefully identifying a sample of 32 children with language disorders whom we then evaluated for short-term verbal and visuospatial memory, verbal and visuospatial working memory, attention, processing speed, and lexical-semantic skills. We then implemented an intervention program on working memory consisting of 72 sessions of 15 minutes each, after which we repeated the neuropsychological assessment of these functions. Children with language disorders performed worse than children in the control group in all memory tasks evaluated and in the lexical-semantic processing task. After the intervention, children with language disorders showed a significant increase over their own previous performance in all variables. Children with language disorders show significant cognitive deficits and not just linguistic impairment. We offer conclusive findings on the effectiveness of the intervention program used. Finally, we obtained partial support for the existence of a causal link between improved performance on memory tasks and performance in a lexical-semantic task.

Effect of a Whole-Person Model of Care on Patient Experience in Patients With Complex Chronic Illness in Late Life

Background:

Patients with serious chronic illness are at a greater risk of depersonalized, overmedicalized care as they move into later life. Existing intervention research on person-focused care for persons in this transitional period is limited.

Objective:

To test the effects of LifeCourse, a team-based, whole-person intervention emphasizing listening to and knowing patients, on patient experience at 6 months.

Design:

This is a quasi-experimental study with patients allocated to LifeCourse and comparison groups based on 2 geographic locations. Robust change-score regression models adjusted for baseline differences and confounding.

Setting/Participants:

Patients (113 intervention, 99 comparison in analyses) were individuals with heart failure or other serious chronic illness, cancer, or dementia who had visits to hospitals at a large multipractice health system in the United States Midwest.

Measurements:

Primary outcome was 6-month change in patient experience measured via a novel, validated 21-item patient experience tool developed specifically for this intervention. Covariates included demographics, comorbidity score, and primary diagnosis.

Results:

At 6 months, LifeCourse was associated with a moderate improvement in overall patient experience versus usual care. Individual domain subscales for care team, communication, and patient goals were not individually significant but trended positively in the direction of effect.

Conclusion:

Person-focused, team-based interventions can improve patient experience with care at a stage fraught with overmedicalization and many care needs. Improvement in patient experience in LifeCourse represents the sum effect of small improvements across different domains/aspects of care such as relationships with and work by the care team.

Does Full Insurance Increase the Demand for Health Care?

We estimate the causal impact of having full health insurance on healthcare expenditures. We take advantage of a unique quasi-experimental setup in which deductibles and co-payments were zero in a managed care plan and nonzero in regular insurance, until a policy change forced all individuals with an active plan to cover a minimum amount of their expenses. Using panel data and a nonlinear difference-in-differences strategy, we find a demand elasticity of about -0.14 comparing full insurance with the cost-sharing model and a significant upward shift in the likelihood to generate costs. Copyright © 2015 John Wiley & Sons, Ltd.

Look into the crystal ball: Can vivid images of the future enhance physical health?

Many impulsive behaviors, unpleasant emotions, and misguided cognitions increase the incidence of type 2 diabetes and other conditions. This study tests the premise that such risk factors are inversely related to future clarity-the extent to which the future seems vivid and certain. Specifically, 211 participants completed the measures of future clarity and various determinants of health. Future clarity was positively associated with the inclination of participants to consume healthy food, abstain from cigarettes, participate in physical activity, and experience positive emotions. Future research should examine whether interventions designed to help individuals clarify and pursue their aspirations could stem lifestyle diseases.

Look into the crystal ball: Can vivid images of the future enhance physical health?

Many impulsive behaviors, unpleasant emotions, and misguided cognitions increase the incidence of type 2 diabetes and other conditions. This study tests the premise that such risk factors are inversely related to future clarity-the extent to which the future seems vivid and certain. Specifically, 211 participants completed the measures of future clarity and various determinants of health. Future clarity was positively associated with the inclination of participants to consume healthy food, abstain from cigarettes, participate in physical activity, and experience positive emotions. Future research should examine whether interventions designed to help individuals clarify and pursue their aspirations could stem lifestyle diseases.

Health Insurance Mandates, Mammography, and Breast Cancer Diagnoses

We examine the effects of state health insurance mandates requiring coverage of screening mammograms. We find evidence that mammography mandates significantly increased mammography screenings by 4.5-25 percent. Effects are larger for women with less than a high school degree in states that ban deductibles, a policy similar to a provision of federal health reform that eliminates cost-sharing for preventive care. We also find that mandates increased detection of early stage in-situ pre-cancers. Finally, we find a substantial proportion of the increased screenings were attributable to mandates that are not consistent with current recommendations of the American Cancer Society.