Experimentation and social interventions: a forgotten but important history Public views on determinants of health, interventions to improve health, and priorities for government. Good intentions and received wisdom are not enough The impact of population-based disease management services for selected chronic conditions: the Costs to Australian Private Insurance - Coaching Health (CAPICHe) study protocol Economic evaluation of treatments for children with severe behavioural problems. Tensions in public health policy: patient engagement, evidence-based public health and health inequalities Conditional cash transfers to improve education and health: an ex ante evaluation of Red de Protección Social, Nicaragua. Improving support for family carers: Key implications for research, policy and practice Evidence, Theory and Context: Using intervention mapping to develop a worksite physical activity intervention The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities - study protocol for a cluster randomized controlled trial Re-thinking the relationship between long-term condition self-management education and the utilisation of health services. Integrating assessments of older people: examining evidence and impact from a randomised controlled trial. Towards systematic reviews that inform health care management and policy-making The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system An international registry of systematic-review protocols Comparative cost analysis of insecticide-treated net delivery strategies: sales supported by social marketing and free distribution through antenatal care. Conditional Cash Transfers And Health Of Low-Income Families In The US: Evaluating The Family Rewards Experiment. Design of the Project NetWork return-to-work experiment for persons with disabilities. Economic Evaluation of a Problem Solving Intervention to Prevent Recurrent Sickness Absence in Workers with Common Mental Disorders 'More research needed': plugging gaps in the evidence base on health inequalities. Citizen Participation in Patient Prioritization Policy Decisions: An Empirical and Experimental Study on Patients' Characteristics A cost-effectiveness analysis of the Incredible Years parenting programme in reducing childhood health inequalities Good intentions and received wisdom are not good enough: the need for controlled trials in public health The effects of expanded mental health benefits on treatment costs. FIRE (facilitating implementation of research evidence): a study protocol Cost of depression in Europe. The limitations of randomized controlled trials in predicting effectiveness. Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience" Large scale food retailing as an intervention for diet and health: quasi-experimental evaluation of a natural experiment Structured re-assessment system at 6 months after a disabling stroke: a randomised controlled trial with resource use and cost study. Effects of an evidence service on health-system policy makers' use of research evidence: A protocol for a randomised controlled trial Next steps for falls and fracture reduction. A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies Occupational therapy compared with social work assessment for older people. An economic evaluation alongside the CAMELOT randomised controlled trial. Cost Effectiveness of the Earned Income Tax Credit as a Health Policy Investment.
The research design of the r and omised controlled trial is primarily associated today with medicine . It tends either to be ignored or regarded with suspicion by many in such disciplines as health promotion , public policy , social welfare , criminal justice , and education . However , all professional interventions in people 's lives are subject to essentially the same questions about acceptability and effectiveness . As the social reformers Sidney and Beatrice Webb pointed out in 1932 , there is far more experimentation going on in “ the world sociological laboratory in which we all live ” than in any other kind of laboratory , but most of this social experimentation is “ wrapped in secrecy ” and thus yields “ nothing to science.”1 # # # Summary points Many social scientists argue that r and omised controlled trials are inappropriate for evaluating social interventions , but they ignore a considerable history , mainly in the United States , of the use of r and omised controlled trials to assess different approaches to public policy and health promotion A tradition of experimental sociology was well established by the 1930s , built on the early use of controlled experiments in psychology and education From the early 1960s to early 1980s r and omised experiments were considered the optimal design for evaluating public policy interventions in the United States , and major evaluations using this design were carried out This approach became less popular as policy makers reacted negatively to evidence of “ near zero ” effects Lessons to be learnt about implementing r and omised controlled trials in real life setting s include the difficulty of assessing complex multi-level interventions and the challenge of integrating qualitative data The Webbs argued for a more “ scientific ” social policy , with social scientists being trained in experimental methods and evaluations of social interventions being carried out by independent investigators . They were apparently unaware that a strong tradition in experimental sociology had already been established , mainly in the United States . OBJECTIVE There is increasing evidence about the importance of factors that impact health beyond health care and individual behavior , yet there is little public and policy discourse about these things in the United States . We surveyed Wisconsin adults to see what they think are the most important factors that affect health . We also examined which interventions they believe would improve health , and whether government should prioritize such interventions . METHODS A phone survey of a r and om sample of 1459 Wisconsin adults was conducted between September 2006 and February 2007 . RESULTS The Wisconsin public believes that health practice s , access to health care , and health insurance are the most important factors affecting health , and that health insurance is a high government priority . Other broader social and economic determinants of health , such as employment , social support , income , housing , and neighborhood factors are seen as less important to health . Although respondents believe that health practice s are important to health , they are less likely to suggest that government prioritize improving individual health practice s. Although the public believes the government should prioritize access to health care and health insurance , they are not as likely to support government implementing social or economic policies in order to improve health . CONCLUSION In light of research demonstrating the importance of social and economic determinants of health , and of ongoing public forums meant to raise awareness of these determinants of health , it will be important to track whether public opinion of Wisconsin adults changes over time to increase attention to the social and economic determinants of health and related policy initiatives There is a common view among social and public health scientists that there is an evidence -based medicine ( EBM ) juggernaut , a powerful , naive , and overweening attempt to impose an inappropriately narrow and medical model of experimentation onto a complex social world . We have both frequently come across hostility among social scientists , and public health or health promotion practitioners or theorists , to attempts to apply EBM principles ( for example , systematic review s or experimental design s ) in social or public health setting s ( for example , sex education in schools , health promotion campaigns , or community development1 ) . We believe such hostility to be misplaced , and to be based on a number of misconceptions . The first misconception is that systematic review s and experimental design s have a wholly biomedical provenance . As Ann Oakley has pointed out , the use of experimental design s was well established in United States by the 1930s , and from the early 1960s to early 1980s there were many r and omised experiments for evaluating public policy interventions in United States , these being considered the optimum design . Much of the early literature on experimental design s ( including blinding ) came from the social sciences , as a response to the perceived need to be able to make valid causal inferences.2 The second misconception is that the “ real world ” is too complex , messy , Background Recent evidence from a large scale trial conducted in the United States indicates that enhancing shared decision-making and improving knowledge , self-management , and provider communication skills to at-risk patients can reduce health costs and utilisation of healthcare re sources . Although this trial has provided a significant advancement in the evidence base for disease management programs it is still left for such results to be replicated and /or generalised for population s in other countries and other healthcare environments . This trial responds to the limited analyses on the effectiveness of providing chronic disease management services through telephone health coaching in Australia . The size of this trial and it 's assessment of cost utility with respect to potentially preventable hospitalisations adds significantly to the body of knowledge to support policy and investment decisions in Australia as well as to the international debate regarding the effect of disease management programs on financial outcomes . Methods Intention to treat study applying a prospect i ve r and omised design comparing usual care with extensive outreach to encourage use of telephone health coaching for those people identified from a risk scoring algorithm as having a higher likelihood of future health costs . The trial population has been limited to people with one or more of the following selected chronic conditions : namely , low back pain , diabetes , coronary artery disease , heart failure , and chronic obstructive pulmonary disease . This trial will enrol at least 64,835 source d from the approximately 3 million Bupa Australia private health insured members located across Australia . The primary outcome will be the total ( non-maternity ) cost per member as reported to the private health insurer ( i.e. charged to the insurer ) 12 months following entry into the trial for each person . Study recruitment will be completed in early 2012 and the results will be available in late 2013 . Discussion If positive , CAPICHe will represent a potentially cost-effective strategy to improve health outcomes in higher risk individuals with a chronic condition , in a private health insurance setting .Trial Registration Australian New Zeal and Clinical Trials Registry reference : BACKGROUND Disruptive behaviour disorders , including conduct disorder , affect at least 10 % of children and are the most common reasons for referral to children 's mental health services . The long-term economic impact on society of unresolved conduct disorder can exceed pound sterling 1 million for one individual over their lifetime . AIMS OF THE STUDY The aim of this study was to estimate , from a multi-sectoral service perspective , the longer term cost-effectiveness of an intensive practice based parenting programme for children with severe behavioural problems as compared to a st and ard treatment , on a pilot basis . METHODS A six-month pragmatic controlled trial was conducted involving forty-two families who had been referred to a Child and Adolescent Mental Health Service ( CAMHS ) because of severe child behavioural problems . The families were r and omly allocated into either the st and ard or intensive , practice -based treatment arms of the trial . At baseline , children were aged 2 to 10 years . The externalising T-scale of the Child Behaviour Check List ( CBCL ) was used as the primary outcome measure . Follow-up studies were conducted at 6 months and four years post-intervention . At the four-year follow up point the two treatments were subjected to an incremental cost-effectiveness analysis . This analysis was enabled by the collection of cost data with respect to the provision of the intensive and st and ard treatments in terms of therapeutic contact time and also participants ' use of health , special educational and social services usage by means of a Client Service Receipt Inventory . RESULTS Both groups exhibited improved behaviour at six month follow-up , but only the practice based treatment group showed sustained improvement at the four-year follow-up . An independent t-test revealed a significant difference between group mean scores at four-year follow-up ( p = 0.027 ) . The research found a median bootstrap ICER estimate of pound sterling 224 From the cost-effectiveness acceptability curve ( CEAC ) it was found that 89.6 % of the cost-effectiveness plane represented a cost saving over the control intervention while 99.9 % represented an improvement in effect . Therefore the intensive intervention could not be said to differ significantly from the control intervention on the basis of costs or effects . However under certain circumstances requiring judgement the intensive intervention could be cost-effective . DISCUSSION Training interventions for the parents of children with severe conduct disorders currently take the form of a number of behavioural strategies provided by a CAMHS team including the reinforcement of appropriate behaviours and parent record-keeping . An alternative treatment was then considered that included all the aspects provided by the st and ard treatment ( with the exception of agreeing written goals ) and also added five-hour sessions of unit-based treatment during which videotaped recording of parent-child interactions were used to give feedback to parents and to provide the opportunity for behavioural rehearsal . The findings of the current research indicate that this alternative treatment may be more cost-effective than the st and ard intervention under certain circumstances . CONCLUSIONS It can be concluded on a pilot basis that while the CEAC failed to show a significant difference between costs and effects for the intensive treatment , under circumstances of re source /effect trade offs the treatment could be said to be cost-effective . IMPLICATION S FOR HEALTH CARE PROVISION , USE AND POLICIES : Health and social care policy and commissioning must be evidence based . Although the analysis in this paper should be considered a pilot due to the small sample size our results suggest that investment by health services and social services in practice -based parenting interventions may well be less costly and more effective in the longer-run than the st and ard practice involving giving management advice to parents . IMPLICATION S FOR FURTHER RESEARCH It would be of interest for further research to continue to follow up the work done in this study with a larger cohort of subjects to further establish the effective components of parenting programmes and their relative costs and benefits both at intervention and over time This paper examines the proposition that there are considerable tensions between key strategies in health policy — namely , evidence -based approaches to population health improvement , reduction of health inequalities , and public and patient engagement — using ( 1 ) a critical analysis of the intersection of evidence -based public health , patient and public engagement , and health inequalities policies from a social constructionist perspective and ( 2 ) mathematical modelling of paternalistic and shared decision making in the management of hypertension in a r and om age and sex stratified community sample of residents of south east Northumberl and , UK . It is concluded that there may be unintended effects on population health of incongruities in major components of public health policy . Greater public and patient engagement may militate against the disease prevention goals of evidence -based policy , and may better engage sections of the population who already benefit from greater access and better health associated with social status and opportunity , serving to increase inequalities by further marginalising those already suffering from relative exclusion Using baseline data from a r and omized experiment , this article extends and tests in the context of health , the feasibility of a recently proposed reduced form approach to ex ante evaluations of social programs with an application to a  conditional cash transfer program in Nicaragua . It uses a behavioural model to estimate the impact on preventive care utilization outcomes for children younger than 3 years . It vali date s the model with the results of the experiment and then simulates two alternate policy scenarios . The model performs well in predicting the health related outcomes and shows different results for the two sets of policy scenarios . In addition , simulations are also carried out for the school component of the cash transfer program The aim of this editorial is to highlight several research priorities and key implication s for policy and practice that inform an agenda to improve family carer support . The development of systematic approaches to identify carers who are at risk of poor psychosocial outcomes  is a priority . Family caregiving should not be pathologised as an inherently negative experience ; however , it would be a breach of care if more than 40 % of carers who appear to meet the criteria for psychological distress1 are not offered suitable supports . Related to this is the urgent need for greater investment in bereavement research ; while bereavement support is integral to palliative care , it is typically under-re source d , under-investigated and not systematic ally applied . We know that routine intervention for all bereaved carers is not warranted . The challenge is to discern those carers who are ‘ at risk ’ prior to the death of the patient and to identify suitable evidence -based strategies to assist them . Research indicates that carer re sources , rather than patient diagnosis or illness severity , are the primary predictors of carer burden and other carer outcomes . This implies that although the specific content may need to vary to suit the context , the core elements of family carer interventions may be relevant across disease groups . It is also apparent that the perceived quality of social support is more important than the size of the social network in improving carer outcomes .2 Current indications are that palliative care providers should assist carers by targeting social support and re sources and provide education that focuses on coping strategies and preparation for the carer role . In many countries , family carers are well prepared for the beginning of life when , for example , prospect i ve parents are routinely offered parenting classes . It is also not uncommon to assist carers prepare for and support relatives having major heart surgery . However , preparation for supporting a relative/ friend at the end of their life is not routinely offered . Carers typically want to know what the role entails , how to manage symptoms , signs of imminent death and re sources and strategies to sustain their own well-being . Given the majority of patients want to be cared for in their home environment , initiatives that assist carers to achieve this are needed . The period of time most people receive palliative care services is typically quite short ; hence , the challenge is to design interventions that are as brief as possible , readily accessible and easily delivered . The significant number of carers who support patients in the hospital/hospice setting should also not be neglected ; their needs are often hidden . Other valuable insights regarding how we deliver interventions are surfacing . For example , the conception that face-to-face carer support is the gold st and ard is being challenged . Emerging evidence suggests that telephone and video phone support may be equally effective in some circumstances.1,3 Emphasis on the development of a strategic , coordinated and priority-driven family carer research agenda is also important.4 The role of formal research collaborations may be a vehicle to foster this . Much of the carer research seems to be first-world centric . More attention needs to be directed towards family caregiving in under-re source d countries and in other under-represented population s such as ethnic minority groups . Several important policy and clinical matters warrant consideration if palliative care is to foster improved carer support . One of the core questions for policymakers and clinicians is whether or not it is feasible for palliative care to be expected to meet the needs of the patients ’ entire family . It has been recommended that given re source constraints , the focus should be on the primary family carer ( as identified by the patient ) and where possible extended to other family members.5 Consideration might also be given to revising expectations about the goal of family support . The current World Health Organization definition of palliative care advocates that families ’ quality of life be improved ; perhaps a more realistic objective may be to aim to reduce the psychosocial burden of primary family carers . A related question is how to effectively legitimise family carer support . Most family carers do not want to discuss their needs and concerns in front of their relative ; they therefore need one-to-one time with healthcare and socialcare professionals . It is also clear that many healthcare workers find supporting carers challenging . Hence , where pertinent , consideration should be given to the potential merits of officially recognising family carers as ‘ care recipients ’ ; therefore , they are formally acknowledged as ‘ worthy ’ within the healthcare system . This may help justify much needed re sources and allow healthcare workers to allocate time and where pertinent offer interventions . In 488855 PMJ27710.1177/0269216313488855Palliative MedicineEditorial Background The workplace is an ideal setting for health promotion . Helping employees to be more physically active can not only improve their physical and mental health , but can also have economic benefits such as reduced sickness absence . The current paper describes the development of a three month theory-based intervention that aims to increase levels of moderate intensity physical activity amongst employees in sedentary occupations . Methods The intervention was developed using an intervention mapping protocol . The intervention was also informed by previous literature , qualitative focus groups , an expert steering group , and feedback from key contacts within a range of organisations . Results The intervention was design ed to target awareness ( e.g. provision of information ) , motivation ( e.g. goal setting , social support ) and environment ( e.g. management support ) and to address behavioural ( e.g. increasing moderate physical activity in work ) and interpersonal outcomes ( e.g. encourage colleagues to be more physically active ) . The intervention can be implemented by local facilitators without the requirement for a large investment of re sources . A facilitator manual was developed which listed step by step instructions on how to implement each component along with a suggested timetable . Conclusion Although time consuming , intervention mapping was found to be a useful tool for developing a theory based intervention . The length of this process has implication s for the way in which funding bodies allow for the development of interventions as part of their funding policy . The intervention will be evaluated in a cluster r and omised trial involving 1350 employees from 5 different organisations , results available September 2009 Background Reducing neonatal-related deaths is one of the major bottlenecks to achieving Millennium Development Goal 4 . Studies in Asia and South America have shown that neonatal mortality can be reduced through community-based interventions , but these have not been adapted to scalable intervention packages for sub-Saharan Africa where the culture , health system and policy environment is different . In Ug and a , health outcomes are poor for both mothers and newborn babies . Policy opportunities for neonatal health include the new national Health Sector Strategic Plan , which now prioritizes newborn health including use of a community model through Village Health Teams ( VHT ) . The aim of the present study is to adapt , develop and cost an integrated maternal-newborn care package that links community and facility care , and to evaluate its effect on maternal and neonatal practice s in order to inform policy and scale-up in Ug and a. Methods / Design Through formative research around evidence -based practice s , and dialogue with policy and technical advisers , we constructed a home-based neonatal care package implemented by the responsible VHT member , effectively a Community Health Worker ( CHW ) . This CHW was trained to identify pregnant women and make five home visits - two before and three just after birth - so that linkages will be made to facility care and targeted messages for home-care and care-seeking delivered . The project is improving care in health units to provide st and ardized care for the mother and the newborn in both intervention and comparison areas .The study is taking place in a new Demographic Surveillance Site in two rural districts , Iganga and Mayuge , in Ug and a. It is a two-arm cluster r and omized controlled design with 31 intervention and 32 control areas ( villages ) . The comparison parishes receive the st and ard care already being provided by the district , but to the intervention villages are added a system for CHWs to visit the mother five times in her home during pregnancy and the neonatal period . Both areas benefit from a st and ardized strengthening of facility care for mothers and neonates . Discussion UNEST is design ed to directly feed into the operationalization of maternal and newborn care in the national VHT strategy , thereby helping to inform scale-up in rural Ug and a. The study is registered as a r and omized controlled trial , number IS RCT N50321130 Encouraging self-management has been viewed as one means of reducing health service utilisation and contributing to improved dem and management . However , the processes and imputed relationship between self-management education skills and health service contact are poorly understood . This paper reports on data from an embedded qualitative study which ran alongside a r and omised controlled trial in Engl and design ed to test the clinical and cost effectiveness of a self-care support policy which found no statistically significant reductions in health service utilisation . Drawing on concepts from the sociology of chronic illness , analyses suggest that the biographical and social context relevant to individuals ' experience of living with a long-term condition , history of health service utilisation , and relationships with health professionals are relevant to underst and ing the impact of self-management education and related policies aim ed at bringing about changes in service use . Our study suggests that future health policy assumptions about utilisation in the context of chronic disease management and self-care support polices may benefit by acknowledging the complex , context ual and recursive nature of health service utilisation operating in the life worlds of patients ' experience of living with a long-term condition SIR — The needs of older people are often multiple , complex and are at times experienced in combination , which require closely targeted services [ 1 ] and necessitate the collaboration of several professional groups . However , care has often been disjointed and compartmentalised [ 2 ] . One response to this has been a call for integration , between health and social care . Integrated care can operate at the organisational level , in terms of structures [ 3 , 4 ] or the professional level , in terms of shared working arrangements , multidisciplinary teams and case management [ 5 , 6 ] ; an issue being that integrated structures , although conducive to interprofessional working , do not necessarily guarantee it [ 7 ] . Integration is assumed to produce benefits in terms of better co-ordination of services , better outcomes and greater efficiency [ 8 ] . Integration remains an aim pursued by successive governments [ 9 ] . Policies in several countries call for integration at the assessment stage ; a key phase in terms of ensuring care closely matches older people ’s needs [ 10 , 11 ] . In Engl and , examples are the single assessment process ( SAP ) , offering a common structure through shared tools and processes [ 12 ] , and the common assessment framework ( CAF ) for adults , advocating technical solutions for information sharing [ 13 ] . However , while evidence identifies potential benefits of integrating assessment information from different professionals [ 5 , 14 ] and of more comprehensive geriatric assessment [ 15 ] , there remains a need to examine the cost-effectiveness of such approaches to guide future policy . We reanalysed data from a r and omised controlled trial of integrated assessment between specialist clinicians and social services care managers in Engl and [ 14 ] to offer evidence of the costs and benefits of integration . We evaluated the experiment ’s impact on changes in functioning , admissions to care homes and use and costs of health and social services for frail older people at risk of entering care homes Objectives To identify ways to improve the usefulness of systematic review s for health care managers and policy-makers that could then be evaluated prospect ively . Methods We systematic ally review ed studies of decision-making by health care managers and policy-makers , conducted interviews with a purposive sample of them in Canada and the United Kingdom ( n=29 ) , and review ed the websites of research funders , producers/purveyors of research , and journals that include them among their target audiences ( n=45 ) . Results Our systematic review identified that factors such as interactions between research ers and health care policy-makers and timing/timeliness appear to increase the prospect s for research use among policy-makers . Our interviews with health care managers and policy-makers suggest that they would benefit from having information that is relevant for decisions highlighted for them ( e.g. context ual factors that affect a review 's local applicability and information about the benefits , harms/risks and costs of interventions ) and having review s presented in a way that allows for rapid scanning for relevance and then grade d entry ( such as one page of take-home messages , a three-page executive summary and a 25-page report ) . Managers and policy-makers have mixed views about the helpfulness of recommendations . Our analysis of websites found that context ual factors were rarely highlighted , recommendations were often provided and grade d entry formats were rarely used . Conclusions Research ers could help to ensure that the future flow of systematic review s will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions . Research funders could help to ensure that the global stock of systematic review s will better inform health care management and policy-making by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly ‘ front ends ’ for potentially relevant systematic review Background Tanzania has been a pioneer in establishing community-level services , yet challenges remain in sustaining these systems and ensuring adequate human re source strategies . In particular , the added value of a cadre of professional community health workers is under debate . While Tanzania has the highest density of primary health care facilities in Africa , equitable access and quality of care remain a challenge . Utilization for many services proven to reduce child and maternal mortality is unacceptably low . Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers , but the Ministry of Health and Social Welfare ( MoHSW ) lacks evidence that this merits national implementation . The Tanzania Connect Project is a r and omized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero , Rufiji , and Ulanga).Description of interventionConnect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality , improve access to services , exp and utilization , and alter reproductive , maternal , newborn and child health seeking behavior ; thereby accelerating progress towards Millennium Development Goals 4 and 5 . Connect has introduced a new cadre — Community Health Agents ( CHA ) — who were recruited from and work in their communities . To support the CHA , Connect developed supervisory systems , launched information and monitoring operations , and implemented logistics support for integration with existing district and village operations . In addition , Connect ’s district-wide emergency referral strengthening intervention includes clinical and operational improvements . Evaluation design Design ed as a community-based cluster-r and omized trial , CHA were r and omly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System ( HDSS ) in the three study districts . To garner detailed information on household characteristics , behaviors , and service exposure , a r and om sub- sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline . The referral system intervention will use baseline , midline , and endline facility-based data to assess systemic changes . Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system . Discussion Global commitment to launching community-based primary health care has accelerated in recent years , with much of the implementation focused on Africa . Despite extensive investment , no program has been guided by a truly experimental study . Connect will not only address Tanzania ’s need for policy and operational research , it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers  in the context of a high density of fixed facilities . Trial registration : IS RCT Support for prospect i ve registration of protocol s for systematic review s has been gathering momentum . The PRISMA statement , a guideline for reporting systematic review s and meta-analyses of studies that evaluate health-care interventions , advocates registration . Well-conducted systematic review s are accepted as the best- quality evidence to inform policy and practice , and the dramatic upward trend in the number of systematic review s published annually ( fi gure ) is set to continue . However , there is currently no single facility for identifying this type of research in advance of the appearance of the results of the review . There is concern about and evidence of publication and selective outcome -reporting biases associated with systematic review s. An open registry of review s captured at the protocol stage would facilitate good practice in systematic review s by providing transparency of the review process and outcomes . Discrepancies between the methods of the published review and those planned in the registered protocol could be more readily identifi ed . Registration might also encourage full publication of the review ’s fi ndings and transparency in changes to methods that could bias fi ndings . In both the prevention and revelation of potential bias , registration should improve quality and increase confi dence that policy or practice informed by the fi ndings of systematic review s are indeed drawing on best- quality evidence . A registry of protocol s of systematic review s could assist those planning new review s and updating existing ones . Easy access to information about ongoing review s should help to optimise the use of fi nite re sources by enabling funding and commissioning agencies to avoid unnecessary duplication and encourage collaboration . A comprehensive registry could also create opportunities for method ological and other research , both within and across disciplines . Existing access to systematic - review protocol s is limited to the outputs of individual organisations , such as the Cochrane and Campbell Collaborations and the Joanna Briggs Institute . The National Public Health Service for Wales is piloting an All Wales Systematic Review s Register , but , up to now , there has been no central ised comprehensive registry of systematic - review protocol s. We are developing an international facility to register the details of ongoing systematic review s in health and social care . Our registry is being established with the existing platform and infrastructure that supports the Data base of Abstract s of Review s of Eff ects ( DARE ) , the NHS Economic Evaluations Data base ( NHS EED ) and the Health Technology Assessment ( HTA ) data base produced by the Centre for Review s and Dissemination . The initial scope of the registry will be limited to systematic review s of the eff ectiveness of health interventions . However , the longterm aim is for the registry to include details of all ongoing systematic review s with a health-related outcome in the broadest sense . Ultimately , inclusion will encompass systematic review s of health-care interventions , and review s of the social determinants of health , of service delivery , and of risk factors and genetic associations . Our web-based registry will off er free public access , be electronically search able , and open to all prospect i ve registrants . Registration will require the provision of a minimum data set , the completeness of which will be checked automatically before registration . After acceptance , the registry ’s entry and protocol for the review , if available , will be loaded on the data base as a permanent entry and a unique identifi cation number issued . An audit trail for any amendments to the information will be available within the record . Links to result ing publications will be added . These provisions ensure that the registry will match the relevant criteria required of clinical trials registries Insecticide-treated nets ( ITNs ) are effective in substantially reducing malaria transmission . Still , ITN coverage in sub-Saharan Africa ( SSA ) remains extremely low . Policy makers are concerned with identifying the most suitable delivery mechanism to achieve rapid yet sustainable increases in ITN coverage . Little is known , however , on the comparative costs of alternative ITN distribution strategies . This paper aim ed to fill this gap in knowledge by developing such a comparative cost analysis , looking at the cost per ITN distributed for two alternative interventions : subsidized sales supported by social marketing and free distribution to pregnant women through antenatal care ( ANC ) . The study was conducted in rural Burkina Faso , where the two interventions were carried out alongside one another in 2006/07 . Cost information was collected prospect ively to derive both a financial analysis adopting a provider 's perspective and an economic analysis adopting a societal perspective . The average financial cost per ITN distributed was US$ 8.08 and US$ 7.21 for sales supported by social marketing and free distribution through ANC , respectively . The average economic cost per ITN distributed was US$ 4.81 for both interventions . Contrary to common belief , costs did not differ substantially between the two interventions . Due to the district 's ability to rely fully on the use of existing re sources , financial costs associated with free ITN distribution through ANC were in fact even lower than those associated with the social marketing campaign . This represents an encouraging finding for SSA governments and points to the possibility to invest in programmes to favour free ITN distribution through existing health facilities . Given restricted budgets , however , free distribution programmes are unlikely to be feasible Opportunity  NYC-Family Rewards was the first conditional cash transfer , r and omized controlled trial for low-income families in the United States . From 2007 to 2010 , Family Rewards offered 2,377 New York City families cash transfers  that were conditional upon their investments in education , preventive health care , and parental employment . Their health and other outcomes were compared to those of a  control group of 2,372 families . The experiment led to a modest improvement in health insurance coverage and a large increase in the use of preventive dental care . It improved parents ' perception of their own health and levels of hope , mainly through improvements in reported financial well-being . While the program 's impacts on physical health were weaker , our study might not have captured effects on chronic disease risk that take longer to accrue . In the context of New York City 's operating social-safety-net programs , conditional cash transfers may have led to positive , albeit modest , improvements in the health of poor families As the Nation 's first rigorous large-scale evaluation of vocational rehabilitation ( VR ) assistance to persons with severe disabilities , the Project NetWork demonstration will provide a wide range of information to policy-makers , research ers , and other interest groups . The evaluation of Project NetWork addresses two key policy questions : Is it feasible to increase participation in  VR services  among Disability Insurance ( DI ) beneficiaries and Supplemental Security Income ( SSI ) applicants/recipients through a combination of intensive outreach , case management , and enhanced work incentives ? Do the interventions tested produce net benefits from the perspective of participants , society , the DI Trust Fund , and the Federal Government , as a whole ? The study utilizes a r and omized field experiment design to evaluate the net impact of the demonstration on participant employment , earnings , receipt of transfer benefits , social and psychological well-being , and other variables of interest to policymakers . A combination of SSA administrative data , information from the demonstration 's onsite management information system ( MIS ) , and in-person interviews ( containing a rich array of information on disability , health , and attitudes ) supports the evaluation . This article summarizes three aspects of the evaluation : Its experimental and sample design ; the methods and data to be used to analyze project benefits , costs , and participation ; and the challenges faced during demonstration implementation . It also presents preliminary data on the characteristics of Project NetWork participants and eligibles Objectives Workers with common mental disorders ( CMDs ) frequently experience recurrent sickness absence  but scientifically evaluated interventions to prevent recurrences are lacking . The objectives of this study are to evaluate the cost-effectiveness and cost-benefit of a problem solving intervention aim ed at preventing recurrent sickness absence in workers with CMDs compared to care as usual  . Methods An economic evaluation was conducted alongside a cluster-r and omised controlled trial with 12 months follow-up . Treatment providers were r and omised to either a 2-day training in the SHARP-at work intervention , i.e. a problem solving intervention , or care as usual . Effect outcomes were the incidence of recurrent sickness absence and time to recurrent sickness absence . Self-reported health care utilisation was measured by question naires . A cost-effectiveness analysis ( CEA ) from the societal perspective and a cost-benefit analysis ( CBA ) from the employer ’s perspective were conducted . Results The CEA showed that the SHARP-at  work intervention was more effective but also more expensive than care as usual . The CBA revealed that employer ’s occupational health care costs were significantly higher in the intervention group compared to care as usual . Overall , the SHARP-at work intervention showed no economic benefit compared to care as usual . Conclusions As implementation of the SHARP-at work intervention might require additional investments , health care policy makers need to decide if these investments are worthwhile considering the results that can be accomplished in reducing recurrent sickness absence Policymakers and public health research ers have dem and ed better evidence of the effects of interventions on public health and health inequalities and have pointed to the relative absence of rigorous outcome evaluations in this area . While most of these commentators agree that health inequalities are a problem , the means of tackling them often seems to rest on poor evidential foundations . This is no longer surprising , as the problem has been well-documented and the solution probably seems clear : if there is not enough evidence , then obviously we need more ; and if the evidence is ‘ weak ’ , well , then , it just needs to be ‘ stronger ’ in future . The funding environment in the UK , at least , is supportive of the production of this new , stronger evidence , with several new funding initiatives which are aim ing to foster the production of new evaluations of public health interventions . However , it might be useful to consider further what ‘ more evidence ’ might look like ( that is , what sort of evidence is needed ) and how might it be ‘ stronger ’ than in the past and also to consider what additional challenges collecting this new evidence might bring . It is clear that evidence on the effectiveness and cost-effectiveness of public health interventions is often missing . Sometimes this is because policies are insufficiently subjected to outcome evaluation , perhaps because it is assumed that they are mostly beneficial and any positive outcomes can be taken as read . R and omized controlled trials of policies are particularly uncommon and there are a variety of real and perceived barriers to trials . This means that the public are frequently ‘ enrolled ’ in real-life policy ‘ experiments ’ without giving their explicit consent , or indeed without any real prospect of anyone learning anything substantial about the effects of those interventions . Although the experimental nature of most policies is generally unacknowledged , this is not always the Health systems worldwide are grappling with the need to control costs to maintain system viability . With the combination of worsening economic conditions , an aging population and reductions in tax revenues , the pressures to make structural changes are expected to continue growing . Common cost control mechanisms , e.g. curtailment of patient access and treatment prioritization , are likely to be adversely viewed by citizens . It seems therefore wise to include them in the decision making processes that lead up to policy changes . In the context of a multilevel iterative mixed- method design a quantitative survey representative of the German population ( N = 2031 ) was conducted to probe the acceptance of priority setting in medicine and to explore the practicability of direct public involvement . Here we focus on preferences for patients ' characteristics ( medical aspects , lifestyle and socio-economic status ) as possible criteria for prioritizing medical services . A question naire with closed response options was fielded to gain insight into attitudes toward broad prioritization criteria of patient groups . Furthermore , a discrete choice experiment was used as a rigorous approach to investigate citizens ' preferences toward specific criteria level in context of other criteria . Both the question naire and the discrete choice experiment were performed with the same sample . The citizens ' own health and social situation are included as explanatory variables . Data were evaluated using corresponding analysis , contingency analysis , logistic regression and a multinomial exploded logit model . The results show that some medical criteria are highly accepted for prioritizing patients whereas socio-economic criteria are rejected Early onset of behavioural problems has lasting negative effects on a broad range of lifetime outcomes , placing large costs on individuals , families and society . A number of research ers and policy makers have argued that early interventions aim ed at supporting the family is the most effective way of tackling child behaviour problems . This study forms the economic component of a r and omised evaluation of the Incredible Years programme , a programme aim ed at improving the skills and parenting strategies of parents of children with conduct problems . Our results show that the programme provides a cost-effective way of reducing behavioural problems . Furthermore , our cost analysis , when combined with a consideration of the potential long-run benefits , suggests that investment in such programmes may generate favourable long-run economic returns In the 1970s Archie Cochrane noted that many healthcare procedures and forms of organisation lacked evidence of effectiveness and efficiency , and argued for improved methods of evaluation , moving from clinical opinion and observation to r and omised controlled trials ( RCTs ) . His arguments gradually became accepted in medicine , but there has been considerable resistance among policymakers and research ers to their application to social and public health interventions . This essay argues that opposition to RCTs in public health is often based on a false distinction between healthcare and community setting s , and sometimes on a misunderst and ing of the principles of RCTs in health care . It suggests that just as in medicine , good intentions and received wisdom are not a sufficient basis for making public policy and allocating public funds for social or health improvement BACKGROUND Mental health disorders represent one of the most common problems facing adults in the labor force . It is estimated that within a 12-month period nearly 30 % of the US population experiences some diagnosable mental health or addictive disorder . This study examines the impact that corporate benefit policies can have on mental health treatment costs . AIMS To measure the effects of a change in mental health benefit design on treatment expenditures for employees of a large US-based company . METHODS Data came from mental health treatment administrative cl aims and eligibility information provided by the company and a comparable set of cl aims for a r and omly selected control group for the years 1995 - 1998 . We measure the effect of a change in mental health benefits consisting of three major elements : a company-wide effort to destigmatize mental illness ; reduced cost-sharing for mental health treatment ; and the implementation of a provider network that emphasized access to non-physician mental health specialists . We use a two-part regression model within a difference in differences framework to examine outpatient , pharmaceutical , and combined outpatient and pharmaceutical expenditures between the treatment company and the control group . RESULTS We find that the program led to a statistically significant dollar 17 increase in outpatient costs ( excluding pharmaceutical costs ) per employee . Similar to outpatient care we find that the benefit change was associated with a statistically significant increase in pharmaceutical costs of about dollar 15 . DISCUSSION The results reveal that the mental health benefit expansion at the company led to a significant increase in aggregate mental health expenditures among employees . However , the aggregate increase in cost masks a number of interesting underlying trends in mental health utilization . First , conditional upon any mental health treatment , mental health costs were virtually unchanged before and after the benefit change . Conditional on any use , outpatient and pharmaceutical expenditures went in opposite directions , with outpatient expenditures falling and pharmaceutical expenditures increasing . IMPLICATION S FOR HEALTH CARE PROVISION AND USE Private sector initiatives can increase use of mental health care treatment through decreased cost-sharing , improved access to specialty providers , and destigmatization of mental disorders . IMPLICATION S FOR HEALTH CARE POLICY FORMULATION : Given that the vast majority of people in the US get their health insurance through employer-sponsored health insurance , efforts on the part of the private sector to recognize and treat serious chronic illnesses such as mental disorder in a proactive manner should be encouraged . IMPLICATION S FOR FUTURE RESEARCH While the aggregate cost of corporate initiatives to improve access to quality mental health care is frequently examined , it is also important to decompose the aggregate cost changes into effects from a change in the rate of initiation and changes in utilization conditional upon initiation Background Research evidence underpins best practice , but is not always used in healthcare . The Promoting Action on Research Implementation in Health Services ( PARIHS ) framework suggests that the nature of evidence , the context in which it is used , and whether those trying to use evidence are helped ( or facilitated ) affect the use of evidence . Urinary incontinence has a major effect on quality of life of older people , has a high prevalence , and is a key priority within European health and social care policy . Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids . Objectives This study aims to advance underst and ing about the contribution facilitation can make to implementing research findings into practice via : extending current knowledge of facilitation as a process for translating research evidence into practice ; evaluating the feasibility , effectiveness , and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management ; assessing the impact of context ual factors on the processes and outcomes of implementation ; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community . Setting and sample Four European countries , each with six long-term nursing care sites ( total 24 sites ) for people aged 60 years and over with documented urinary incontinence Methods and design Pragmatic r and omised controlled trial with three arms ( st and ard dissemination and two different programmes of facilitation ) , with embedded process and economic evaluation . The primary outcome is compliance with the continence recommendations . Secondary outcomes include proportion of residents with incontinence , incidence of incontinence-related dermatitis , urinary tract infections , and quality of life . Outcomes are assessed at baseline , then at 6 , 12 , 18 , and 24 months after the start of the facilitation interventions . Detailed context ual and process data are collected throughout , using interviews with staff , residents and next of kin , observations , assessment of context using the Alberta Context Tool , and documentary evidence . A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances . Trial registration Current Controlled Trials IS RCT N11598502 BACKGROUND Depression is one of the most disabling diseases , and causes a significant burden both to the individual and to society . WHO data suggests that depression causes 6 % of the burden of all diseases in Europe in terms of disability adjusted life years ( DALYs ) . Yet , the knowledge of the economic impact of depression has been relatively little research ed in Europe . AIMS OF THE STUDY The present study aims at estimating the total cost of depression  in Europe based on published epidemiologic and economic evidence . METHODS A model was developed to combine epidemiological and economic data on depression in Europe to estimate the cost . The model was populated with data collected from extensive literature review s of the epidemiology and economic burden of depression in Europe . The cost data was calculated as annual cost per patient , and epidemiologic data was reported as 12-month prevalence estimates . National and international statistics for the model were retrieved from the OECD and Eurostat data bases . The aggregated annual cost estimates were presented in Euro for 2004 . RESULTS In 28 countries with a population of 466 million , at least 21 million were affected by depression . The total annual cost of depression in Europe was estimated at Euro 118 billion in 2004 , which corresponds to a cost of Euro 253 per inhabitant . Direct costs alone totalled dollar 42 billion , comprised of outpatient care ( Euro 22 billion ) , drug cost ( Euro 9 billion ) and hospitalization ( Euro 10 billion ) . Indirect costs due to morbidity and mortality were estimated at Euro 76 billion . This makes depression the most costly brain disorder in Europe , accounting for 33 % of the total cost . The cost of depression corresponds to 1 % of the total economy of Europe ( GDP ) . DISCUSSION Our cost results are in good agreement with previous research findings . The cost estimates in the present study are based on model simulations for countries where no data was available . The predictability of our model is limited to the accuracy of the input data employed . As there is no earlier cost-of-illness study conducted on depression in Europe , it is , however , difficult to evaluate the validity of our results for individual countries and thus further research is needed . CONCLUSION The cost of depression poses a significant economic burden to European society . The simulation model employed shows good predictability of the cost of depression in Europe and is a novel approach to estimate the cost-of-illness in Europe . IMPLICATION S FOR HEALTH CARE PROVISION AND POLICIES : Health and social care policy and commissioning must be evidence -based . The empirical results from this study confirm previous findings , that depression is a major concern to the economic welfare in Europe which has consequences to both healthcare providers and policy makers . One important way to stop this explosion in cost is through increased research efforts in the field . Moreover , better detection , prevention , treatment and patient management are imperatives to reduce the burden of depression and its costs . Mental healthcare policies and better access to healthcare for mentally ill are other challenges to improve for Europe . IMPLICATION S FOR FURTHER RESEARCH This study has identified several research gaps which are of interest for future research . In order to better underst and the impact of depression to European society long-term prospect i ve epidemiology and cost-of-illness studies are needed . In particular data is lacking for Central European countries . On the basis of our findings , further economic evaluations of treatments for depression are necessary in order to ensure a cost-effective use of European healthcare budgets What kinds of evidence reliably support predictions of effectiveness for health and social care interventions ? There is increasing reliance , not only for health care policy and practice but also for more general social and economic policy deliberation , on evidence that comes from studies whose basic logic is that of JS Mill 's method of difference . These include r and omized controlled trials , case-control studies , cohort studies , and some uses of causal Bayes nets and counterfactual-licensing models like ones commonly developed in econometrics . The topic of this paper is the ' external validity ' of causal conclusions from these kinds of studies . We shall argue two cl aims . Cl aim , negative : external validity is the wrong idea ; cl aim , positive : ' capacities ' are almost always the right idea , if there is a right idea to be had . If we are right about these cl aims , it makes big problems for policy decisions . Many advice guides for grading policy predictions give top grade s to a proposed policy if it has two good Mill's- method -of difference studies that support it . But if capacities are to serve as the conduit for support from a method -of-difference study to an effectiveness prediction , much more evidence , and much different in kind , is required . We will illustrate the complexities involved with the case of multisystemic therapy , an internationally adopted intervention to try to diminish antisocial behaviour in young people Background Most research publications on Chronic Care Model ( CCM ) implementation originate from organizations or countries with a well-structured primary health care system . Information about efforts made in countries with a less well-organized primary health care system is scarce . In 2003 , the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting , a setting where the organisational framework for chronic care is mainly hospital-centered . Methods Process evaluation of an action research project ( 2003–2007 ) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients . In consultation with the region a program for type 2 diabetes patients was developed . The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey ( ACIC ) . A multi method approach was used to evaluate the implementation process . The result ing data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process . Results The overall ACIC score improved from 1.45 ( limited support ) at the start of the study to 5.5 ( basic support ) at the end of the study . The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care . The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator . Important barriers were the complexity of the intervention , the lack of quality data , inadequate information technology support , the lack of commitment procedures and the uncertainty about sustainable funding . Conclusion Guided by the CCM , this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure . The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers . Currently primary care providers lack the opportunities to take up full responsibility for chronic care . Trial registration number Clinical Trials.gov Identifier : Objectives : To assess the effect on fruit and vegetable consumption , self reported , and psychological health of a “ natural experiment”—the introduction of large scale food retailing in a deprived Scottish community . Design : Prospect i ve quasi-experimental design comparing baseline and follow up data in an “ intervention ” community with a matched “ comparison ” community in Glasgow , UK . Participants : 412 men and women aged 16 or over for whom follow up data on fruit and vegetable consumption and GHQ-12 were available . Main outcome measures : Fruit and vegetable consumption in portions per day , poor self reported health , and poor psychological health ( GHQ-12 ) . Main results : Adjusting for age , sex , educational attainment , and employment status there was no population impact on daily fruit and vegetable consumption , self reported , and psychological health . There was some evidence for a net reduction in the prevalence of poor psychological health for residents who directly engaged with the intervention . Conclusions : Government policy has advocated using large scale food retailing as a social intervention to improve diet and health in poor communities . In contrast with a previous uncontrolled study this study did not find evidence for a net intervention effect on fruit and vegetable consumption , although there was evidence for an improvement in psychological health for those who directly engaged with the intervention . Although definitive conclusions about the effect of large scale retailing on diet and health in deprived communities can not be drawn from non-r and omised controlled study design s , evaluations of the impacts of natural experiments may offer the best opportunity to generate evidence about the health impacts of retail interventions in poor communities BACKGROUND national policy recommends routine re- assessment of disabled patients and their carers at 6 months after stroke onset . The clinical and re source outcomes of this policy were investigated . DESIGN prospect i ve , single-blind , r and omised controlled trial in two centres . PARTICIPANTS a total of 265 patients with a disabling stroke and their carers . INTERVENTIONS a structured re- assessment system for patients and their carers at 6 months post-stroke or existing care . OUTCOME MEASURES primary : patient independence ( Frenchay activities index ) and carer stress ( general health question naire 28 ) . Secondary : activities of daily living , mood state , satisfaction with services , carer strain index , health and social service re source use and costs . RESULTS independence at 12 months post-stroke was similar in both groups ( Frenchay activities index , adjusted mean difference 0.64 ; 95 % confidence interval -0.74 - 2.02 ) . Emotional distress in carers was similar in both groups ( general health question naire 28 , mean difference 0.02 ; 95 % confidence interval -0.95 - 1.00 ) . Results for the secondary outcome measures and total mean costs were similar for both groups . The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days . CONCLUSIONS the structured , systematic re- assessment for patients and their carers was not associated with any clinical ly significant evidence of benefit at 12 months . Health and social care re source use and mean cost per patient were broadly similar in both groups . TRIAL REGISTRATION International St and ard R and omised Controlled Trial Register ; number : IS RCT N55412871 Background Health-system policy makers need timely access to synthesis ed research evidence to inform the policy-making process . No efforts to address this need have been evaluated using an experimental quantitative design . We developed an evidence service that draws inputs from Health Systems Evidence , which is a data base of policy-relevant systematic review s. The review s have been ( a ) categorised by topic and type of review ; ( b ) coded by the last year search es for studies were conducted and by the countries in which included studies were conducted ; ( c ) rated for quality ; and ( d ) linked to available user-friendly summaries , scientific abstract s , and full-text reports . Our goal is to evaluate whether a " full-serve " evidence service increases the use of synthesized research evidence by policy analysts and advisors in the Ontario Ministry of Health and Long-Term Care ( MOHLTC ) as compared to a " self-serve " evidence service . Methods / design We will conduct a two-arm r and omized controlled trial ( RCT ) , along with a follow-up qualitative process study in order to explore the findings in greater depth . For the RCT , all policy analysts and policy advisors ( n = 168 ) in a single division of the MOHLTC will be invited to participate . Using a stratified r and omized design , participants will be r and omized to receive either the " full-serve " evidence service ( data base access , monthly e-mail alerts , and full-text article availability ) or the " self-serve " evidence service ( data base access only ) . The trial duration will be ten months ( two-month baseline period , six-month intervention period , and two month cross-over period ) . The primary outcome will be the mean number of site visits/month/user between baseline and the end of the intervention period . The secondary outcome will be participants ' intention to use research evidence . For the qualitative study , 15 participants from each trial arm ( n = 30 ) will be purposively sample d. One-on-one semi-structured interviews will be conducted by telephone on their views about and their experiences with the evidence service they received , how helpful it was in their work , why it was helpful ( or not helpful ) , what aspects were most and least helpful and why , and recommendations for next steps . Discussion To our knowledge , this will be the first RCT to evaluate the effects of an evidence service specifically design ed to support health-system policy makers in finding and using research evidence .Trial registration Clinical Trials.gov : In July the Department of Health ( DH ) in Engl and published a toolkit of re sources to promote more effective services to reduce the burden of  falls and fractures in older people . Unfortunately , there is plenty of evidence that the present provision of falls services is suboptimal . The toolkit is part of a ‘ Prevention Package ’ aim ed primarily at commissioners of care , in an attempt to achieve a more consistent and integrated approach to a range of prevention issues in older people [ 1 ] . Falls are a major international public health challenge because of the myriad effects on older individuals : direct physical and psychological injury ; fear of falling and activity limitation ; reduced social participation and quality of life ; increased dependence [ 2–5 ] ; and because of the economic impact on health and social care providers [ 6 , 7 ] . Studies from various countries have shown that about one third of people aged above 65 years fall each year . In UK primary care population s , the rate rises with age to over 60 % of nonagenarians , and is generally higher in women [ 8 ] and in socio-economically deprived population s [ 9 ] . Fragility fractures are the commonest significant injury , 300,000 annually in the UK including upwards of 70,000 hip fractures . Many falls go unreported , but nevertheless they account for 40 % of UK ambulance call-outs , with the variable proportion being conveyed to hospital accounting for one in ten Emergency Department ( ED ) attendances of the over 75s [ 6 ] , a third of whom are admitted , thus comprising about 14 % of emergency admissions . Identifying all falls related activity is challenging but recent estimates suggest that it accounts for between 10 % and 25 % of all local health and social care spending on older people [ 10 ] . Care of fragility fractures is particularly expensive , total health and social care costs in the UK being around £ 2 billion , most of which relates to hip fractures [ 11 ] . Current population and incidence projections suggest that by 2020 , this figure will rise by 50 % . Early in the development of geriatric medicine , falls were identified as a ‘ geriatric giant’—adverse in their own right but also a non-specific indicator of functional decompensation . Building on clarification of falls risk factors [ 12 ] , r and omised controlled trials demonstrated the effectiveness of risk factor based multi-factorial interventions [ 13 , 14 ] . This led to the notion of ‘ falls prevention services ’ . Based on international consensus about what constituted best clinical practice [ 15 ] , broadly similar policies have been developed by the responsible government departments of the four UK nations , and in Irel and [ 16 ] . The National Service Framework for Older People in Engl and ( NSF , 2001 ) [ 17 ] required health services and their local council partners to develop integrated services by April 2005 , incorporating case finding , assessment and referral systems and specialist falls and fragility fracture services . The NSF was launched without earmarked implementation funding , but there was plenty of activity , some enabled and directed by various government initiatives , encouraging community engagement . An independent postal question naire survey to health and social care agencies about their falls services in 2004 [ 18 ] reported most having made plans for an integrated service but implementation was patchy and focused on widely differing priorities . Only 30 % included systems for identifying high risk individuals and only 13 % of falls prevention programmes included exercise classes , the most effective prevention strategy [ 19 ] whilst interventions with little or no evidence base were promoted [ 20 ] . Implementation of these policies across Engl and , Wales and Northern Irel and has been monitored in a series of government funded national audits run by the Royal College of Physicians of London ( RCP ) . The first of these confirmed major gaps at the organisational level , particularly in case finding and referrals for secondary prevention [ 21 ] . A subsequent patient level clinical care audit of fragility fracture patients showed that most returning home from the Emergency Department were not offered a falls risk assessment and only one third were on appropriate treatment for osteoporosis 3 months later [ 22 ] . Despite intense interest among clinicians in the UK and appointment of many geriatricians with a focus on falls , syncope and orthogeriatrics , a repeat organisational audit showed that by 2008 there had been little improvement in service structure , capacity or processes [ 23 ] . Meanwhile the picture was clouded by the negative results of a DH funded systematic review with meta-analyses [ 24 ] . This suggested that the variable outcomes of clinical trials might be associated with the way that the multifactorial approach was organised . There are now several negative outcome trials employing the strategy of nurse led case finding linked to interventions intended to be provided by a range of unconnected professions acting on referral [ 25 ] . In clinical practice , it is likely that there is even more differential effectiveness depending on case finding and referral practice s and context ual differences in service delivery . Research evidence is still lacking on how to achieve much that the NSF aspired to , but there is sufficient evidence and examples of successful implementation to do much better than most are currently doing . So how will the latest government action help ? A key step is to clarify priorities and to put available re sources into the activities likely to make Context Significant re sources and time are invested in the production of research knowledge . The primary objective of this r and omized controlled trial was to evaluate the effectiveness of three knowledge translation and exchange strategies in the incorporation of research evidence into public health policies and programs . Methods This trial was conducted with a national sample of public health departments in Canada from 2004 to 2006 . The three interventions , implemented over one year in 2005 , included access to an online registry of research evidence ; tailored messaging ; and a knowledge broker . The primary outcome assessed the extent to which research evidence was used in a recent program decision , and the secondary outcome measured the change in the sum of evidence -informed healthy body weight promotion policies or programs being delivered at health departments . Mixed-effects models were used to test the hypotheses . Findings One hundred and eight of 141 ( 77 % ) health departments participated in this study . No significant effect of the intervention was observed for primary outcome ( p < 0.45 ) . However , for public health policies and programs ( HPPs ) , a significant effect of the intervention was observed only for tailored , targeted messages ( p < 0.01 ) . The treatment effect was moderated by organizational research culture ( e.g. , value placed on research evidence in decision making ) . Conclusion The results of this study suggest that under certain conditions tailored , targeted messages are more effective than knowledge brokering and access to an online registry of research evidence . Greater emphasis on the identification of organizational factors is needed in order to implement strategies that best meet the needs of individual organizations . Trial Registration The trial registration number and title are as follows : IS RCT N35240937 -- Is a knowledge broker more effective than other strategies in promoting evidence -based physical activity and healthy body weight programming OBJECTIVES To compare costs and outcome of occupational therapy-led assessment with social worker-led assessment of older people , in terms of their independence and quality of life . DESIGN Cost-effectiveness analysis alongside a r and omised controlled trial . The analysis took viewpoints of health services and patients . The primary outcome measure for cost-effectiveness was dependency using the Community Dependency Index ( CDI ) . Secondary outcomes included utility scores based on the EuroQoL ( EQ-5D ) . Re source use was measured for each patient , from clinical records and from patient carer interviews at 8 months . Unit costs of health and social care re sources were derived from local sources and national data sets . Cost-effectiveness was analysed using cost-effectiveness acceptability curves . RESULTS There were no differences between the two arms of the trial in terms of cost-effectiveness . There is an apparent increase in mean cost per case for the occupational therapy arm but this is not statistically significant ( mean difference in cost per case 542 pounds , 95 % CI 434 - 1,519 pounds ) . Mean total costs of care per participant were 4,379 pounds and 3,837 pounds for the occupational therapy and social work arms , respectively . At best the intervention would improve outcomes at a cost of 14,000 pounds per quality -adjusted life year ( QALY ) . The probability of such an outcome was < 50 % . CONCLUSIONS From a policy perspective , the lack of difference in clinical and cost-effectiveness means that either a social work or an occupational therapy service is successful in making care assessment s that enable an older person to remain in their own home INTRODUCTION Lower-income Americans are suffering from declines in income , health , and longevity over time . Income and employment policies have been proposed as a potential non-medical solution to this problem . METHODS An interrupted time series analysis of state-level incremental supplements to the Earned Income Tax Credit ( EITC ) program  was performed using data from 1993 to 2010 Behavioral Risk Factor Surveillance System surveys and state-level life expectancy . The cost effectiveness of state EITC supplements was estimated using a microsimulation model , which was run in 2015 . RESULTS Supplemental EITC programs  increased health-related quality of life and longevity among the poor . The program costs about $ 7,786/ quality -adjusted life-year gained ( 95 % CI=$4,100 , $ 13,400 ) for the average recipient . This ratio increases with larger family sizes , costing roughly $ 14,261 ( 95 % CI=$8,735 , $ 19,716 ) for a family of three . CONCLUSIONS State supplements to EITC appear to be highly cost effective , but r and omized trials are needed to confirm these findings
Our comprehensive review and meta- analysis of these experiments find suggestive evidence of health benefits associated with investments in early life , income support , and health insurance interventions .
Housing and neighborhood trials had no effect on the outcomes included in the meta-analyses .
A positive effect of the trial on its primary socioeconomic outcome was associated with higher odds of reporting health improvements .
Early life , income , and health insurance interventions have the potential to improve health .
Policy Points Social policies might not only improve economic well-being , but also health .
Health policy experts have therefore advocated for investments in social policies both to improve population health and potentially reduce health system costs .
Since the 1960s , a large number of social policies have been experimentally evaluated in the United States .
Some of these experiments include health outcomes , providing a unique opportunity to inform evidence -based policymaking .
CONTEXT Insurers and health care providers are investing heavily in nonmedical social interventions in an effort to improve health and potentially reduce health care costs .