AJPH PERSPECTIVES
could also be redefined by new regulation. How the states use any increased flexibility could be to the benefit of public health, but worrisome to those who want such provisions to be in federal law. This may be regarded as a less favorable outcome because of the lack of a guarantee, but not necessarily less favorable to public health.
THE ECONOMY Finally, to the extent that President Trump is successful in improving the economy and the availability of jobs, the literature on the social determinants of health would suggest that there should be a clear improvement in the health of the population. The uncertainty about how a new Trump Administration and a Republican Congress will
regard public health is substantial. However, Trump’s decision to put in place a 100-day hiring freeze, other than for those in public safety and public health, suggests that the new Administration may regard public health as different from other services in terms of its support and potentially its protection.
February 2017, Vol 107, No. 2
AJPH
desirability bias is part of the explanation. Also, pollsters had to deal with undecided voters, which may have given polls an almost unavoidable uncertainty. Furthermore, numbers are easier to translate into percentages than into the distribution of electors, and this is why polls did a better job of predicting the popular vote than of predicting the majority of electors. A crucial element of further study and discussion, however, may relate to the turnout of groups that either could not be reached by the polls or were not willing to participate in the surveys. Indeed, the average voter turnout of almost 56%, with a highest rate of more than 68% in New Hampshire, is substantially larger than the approximately 10% response in many polls.1,2 Although a low response is not necessarily a problem in itself, selective participation easily gives rise to survey error. An analysis of the 2015 UK general elections suggests that of all these reasons, low response in surveys leading to unrepresentative samples may be the most important problem.3
1. Gandel S. The economy was more important than anything, the exit polls say. Fortune. November 8, 2016. Available at: http://fortune.com/2016/11/08/ election-economy-exit-polls. Accessed December 2, 2016. 2. Kirzinger A, Sugarman E, Brodie M. Kaiser health tracking poll: October 2016. Kaiser Family Foundation. Available at: http://KFF.org/health-costs//pollfinding/Kaiser-health-tracking-pollOctober-2016. Accessed December 2, 2016.
Gail R. Wilensky, PhD
Polls, the Election, and Public Health Research: Reaching the Hard to Reach With the election of Donald Trump as the 45th president of the United States, speculations about the impact of his presidency on the nation’s health care policy have begun. A first lesson, however, can already be learned. Over the past year, polls continually suggested a Democratic president, but ultimately the Republican candidate was elected. Surely, this will be the subject of in-depth research, and several explanations will be considered. For example, survey respondents may have changed their minds in the period between the polls and the elections as a result of new information. The reopening of the Federal Bureau of Investigation’s investigation into Hillary Clinton’s mail server use is an example of this mechanism. This cannot be the entire explanation, though, as the polls still predicted her to win the day before the election. An often heard, but more difficult to investigate, explanation relates to a potential discrepancy between expressed intentions and actual voting behavior. Perhaps more than in previous elections, social
REFERENCES
ELECTION POLLS VS PUBLIC HEALTH SURVEYS This finding relates to what is observed in public health research. Those not participating in election polls may also not be inclined to participate in public health surveys. Indeed, survey research is increasingly grounded on low and selective response rates. Involving so-called hard-to-reach groups in public health research is complex and is particularly relevant in health disparities research.4 To describe the magnitude of health disparities by education or income levels, the participation of substantially large random samples of each socioeconomic stratum is pivotal. What would the consequence be if everyone who voted also completed health surveys? The
possibility cannot be excluded that health disparities would be found to be larger than is currently reported. Regardless of the direction of the impact, however, the polls remind us that reaching and including groups that are currently underrepresented in studies may affect the final result and therefore deserve more attention. Although this point is by no means new,5 if we are serious about accurately describing the size of health disparities, more emphasis on selective nonresponse is warranted. For example, research suggests that poststratification is not always sufficient to remove the impact of selection bias in surveys entirely, and the application of advanced methodology needs serious consideration.6
NONRANDOM SELECTION What adds to the complexity of predicting elections is that
ABOUT THE AUTHOR Frank J. van Lenthe is with the Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands. Correspondence should be sent to Frank J. van Lenthe, professor, Department of Public Health, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA, the Netherlands (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This editorial was accepted November 17, 2016. doi: 10.2105/AJPH.2016.303588
van Lenthe
Editorial
237
AJPH PERSPECTIVES
voter turnout often is not a random sample either. In fact, presidential candidates are very much aware of the importance of motivating subgroups in the population to cast ballots. In the end, these groups can make a difference. Actual participation in public health interventions is also not random. An equity-specific analysis of obesity-related lifestyle programs, for example, illustrates very low participation rates among the lowest socioeconomic groups.7 Again, such findings raise the question of how to engage these groups in research and intervention studies.
REACHING THE HARD TO REACH Clinton’s lack of campaigning and loss in Wisconsin suggest that reaching population subgroups is a matter of effort, but this is probably only a small part of the story. There is a real need in public health to better understand the reasons for the low participation rates of socioeconomically disadvantaged groups in surveys and in public health interventions. As in the decision of whether to vote, the broader circumstances in which persons live and work may play an essential role. For example, those who experience financial problems, poor housing circumstances,
and work-related stress may give participation in research or interventions a much lower priority than those who do not. Approaches need to be developed that align with these circumstances. A first lesson from the elections is that reaching hard-to-reach groups is a currently underestimated issue that deserves a more prominent place in public health research. Frank J. van Lenthe REFERENCES 1. McDonald MP. United States elections project. Available at: http://www.electproject.org/ 2016g. Accessed November 9, 2016. 2. Cassino D. How today’s political polling works. 2016. Available at:
Leveraging Housing Vouchers to Address Health Disparities The Center for Medicare and Medicaid Services’ recently announced Accountable Health Communities (AHC) model aims to better integrate social needs into the clinical realm. Housing quality and insecurity is a core area that providers should screen for and address by linking beneficiaries with community service agencies. However, the effectiveness of the AHC model may be limited if there is a paucity of services to meet the needs that health care providers identify and if these services are not optimized to improve health. Changes in housing policy that better enable low-income families to live in low-poverty neighborhoods that promote health are critical in advancing the goals of the AHC model. Since the 1970s, housing policy has shifted away from
238
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Miles et al.
building housing developments toward providing vouchers that help pay the costs of private rentals. The Housing Choice Voucher Program (commonly known as Section 8 vouchers) helps more than two million low-income families secure affordable housing. When vouchers are used to help families move to low-poverty neighborhoods, they have been shown to improve health outcomes. The Moving to Opportunity for Fair Housing (MTO) experiment of the Department of Housing and Urban Development (HUD) was a decade-long randomized controlled trial involving the participation of 4600 families with children. By the end of the MTO study period, women who had received a voucher to move to a low-poverty neighborhood were less likely than members of
a control group to have diabetes and to be extremely obese.1 Although housing vouchers have been shown to provide essential support to the families that receive them, their effectiveness in offering access to more advantaged neighborhoods has been more limited. Only 15% of all children in families that receive vouchers live in lowpoverty neighborhoods (those with poverty rates below 10%), whereas 18% live in neighborhoods with the most extreme poverty (those with poverty
https://hbr.org/2016/08/how-todayspolitical-polling-works. Accessed November 8, 2016. 3. Mellon J, Prosse C. Missing non-voters and misweighted samples: explaining the 2015 Great British polling miss. Available at: https://papers.ssrn.com/sol3/papers. cfm?abstract_id=2631165. Accessed November 10, 2016. 4. Demarest S, Van der Heyden J, Charafeddine R, Tafforeau J, Van Oyen H, Van Hal G. Socio-economic differences in participation of households in a Belgian national health survey. Eur J Public Health. 2013;23(6):981–985. 5. Galea S, Tracy M. Participation rates in epidemiologic studies. Ann Epidemiol. 2007;17(9):643–653. 6. Gelman A, Goel S, Rivers D, Rothschild D. The mythical swing voter. Quart J Polit Sci. 2016;11(1):103–130. 7. Magn´ee T, Burdorf A, Brug J, et al. Equity-specific effects of 26 Dutch obesity-related lifestyle interventions. Am J Prev Med. 2013;44(6):e57–e66.
rates of 40% or more). Minority voucher holders are more likely than nonminority ones to live in these extreme-poverty neighborhoods.2 Multiple structural barriers prevent voucher recipients from renting in “opportunity” neighborhoods, defined as stable, low-poverty neighborhoods with high-performing schools, low crime and unemployment rates, and access to jobs. First and foremost, the supply of rental housing in these areas may be limited. Second, higher rents in more advantaged neighborhoods are unaffordable, even with assistance. In the voucher program, participants pay approximately one third of their income on
ABOUT THE AUTHORS D. R. Bailey Miles is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Barbara Samuels is with the American Civil Liberties Union of Maryland, Baltimore. Craig E. Pollack is with the Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine. Correspondence should be sent to Craig E. Pollack, MD, MHS, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E Monument St, Suite 2-519, Baltimore, MD 21287 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted November 4, 2016. doi: 10.2105/AJPH.2016.303565
AJPH
February 2017, Vol 107, No. 2
could also be redefined by new regulation. How the states use any increased flexibility could be to the benefit of public health, but worrisome to those who want such provisions to be in federal law. This may be regarded as a less favorable outcome because of the lack of a guarantee, but not necessarily less favorable to public health.
THE ECONOMY Finally, to the extent that President Trump is successful in improving the economy and the availability of jobs, the literature on the social determinants of health would suggest that there should be a clear improvement in the health of the population. The uncertainty about how a new Trump Administration and a Republican Congress will
regard public health is substantial. However, Trump’s decision to put in place a 100-day hiring freeze, other than for those in public safety and public health, suggests that the new Administration may regard public health as different from other services in terms of its support and potentially its protection.
February 2017, Vol 107, No. 2
AJPH
desirability bias is part of the explanation. Also, pollsters had to deal with undecided voters, which may have given polls an almost unavoidable uncertainty. Furthermore, numbers are easier to translate into percentages than into the distribution of electors, and this is why polls did a better job of predicting the popular vote than of predicting the majority of electors. A crucial element of further study and discussion, however, may relate to the turnout of groups that either could not be reached by the polls or were not willing to participate in the surveys. Indeed, the average voter turnout of almost 56%, with a highest rate of more than 68% in New Hampshire, is substantially larger than the approximately 10% response in many polls.1,2 Although a low response is not necessarily a problem in itself, selective participation easily gives rise to survey error. An analysis of the 2015 UK general elections suggests that of all these reasons, low response in surveys leading to unrepresentative samples may be the most important problem.3
1. Gandel S. The economy was more important than anything, the exit polls say. Fortune. November 8, 2016. Available at: http://fortune.com/2016/11/08/ election-economy-exit-polls. Accessed December 2, 2016. 2. Kirzinger A, Sugarman E, Brodie M. Kaiser health tracking poll: October 2016. Kaiser Family Foundation. Available at: http://KFF.org/health-costs//pollfinding/Kaiser-health-tracking-pollOctober-2016. Accessed December 2, 2016.
Gail R. Wilensky, PhD
Polls, the Election, and Public Health Research: Reaching the Hard to Reach With the election of Donald Trump as the 45th president of the United States, speculations about the impact of his presidency on the nation’s health care policy have begun. A first lesson, however, can already be learned. Over the past year, polls continually suggested a Democratic president, but ultimately the Republican candidate was elected. Surely, this will be the subject of in-depth research, and several explanations will be considered. For example, survey respondents may have changed their minds in the period between the polls and the elections as a result of new information. The reopening of the Federal Bureau of Investigation’s investigation into Hillary Clinton’s mail server use is an example of this mechanism. This cannot be the entire explanation, though, as the polls still predicted her to win the day before the election. An often heard, but more difficult to investigate, explanation relates to a potential discrepancy between expressed intentions and actual voting behavior. Perhaps more than in previous elections, social
REFERENCES
ELECTION POLLS VS PUBLIC HEALTH SURVEYS This finding relates to what is observed in public health research. Those not participating in election polls may also not be inclined to participate in public health surveys. Indeed, survey research is increasingly grounded on low and selective response rates. Involving so-called hard-to-reach groups in public health research is complex and is particularly relevant in health disparities research.4 To describe the magnitude of health disparities by education or income levels, the participation of substantially large random samples of each socioeconomic stratum is pivotal. What would the consequence be if everyone who voted also completed health surveys? The
possibility cannot be excluded that health disparities would be found to be larger than is currently reported. Regardless of the direction of the impact, however, the polls remind us that reaching and including groups that are currently underrepresented in studies may affect the final result and therefore deserve more attention. Although this point is by no means new,5 if we are serious about accurately describing the size of health disparities, more emphasis on selective nonresponse is warranted. For example, research suggests that poststratification is not always sufficient to remove the impact of selection bias in surveys entirely, and the application of advanced methodology needs serious consideration.6
NONRANDOM SELECTION What adds to the complexity of predicting elections is that
ABOUT THE AUTHOR Frank J. van Lenthe is with the Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands. Correspondence should be sent to Frank J. van Lenthe, professor, Department of Public Health, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA, the Netherlands (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This editorial was accepted November 17, 2016. doi: 10.2105/AJPH.2016.303588
van Lenthe
Editorial
237
AJPH PERSPECTIVES
voter turnout often is not a random sample either. In fact, presidential candidates are very much aware of the importance of motivating subgroups in the population to cast ballots. In the end, these groups can make a difference. Actual participation in public health interventions is also not random. An equity-specific analysis of obesity-related lifestyle programs, for example, illustrates very low participation rates among the lowest socioeconomic groups.7 Again, such findings raise the question of how to engage these groups in research and intervention studies.
REACHING THE HARD TO REACH Clinton’s lack of campaigning and loss in Wisconsin suggest that reaching population subgroups is a matter of effort, but this is probably only a small part of the story. There is a real need in public health to better understand the reasons for the low participation rates of socioeconomically disadvantaged groups in surveys and in public health interventions. As in the decision of whether to vote, the broader circumstances in which persons live and work may play an essential role. For example, those who experience financial problems, poor housing circumstances,
and work-related stress may give participation in research or interventions a much lower priority than those who do not. Approaches need to be developed that align with these circumstances. A first lesson from the elections is that reaching hard-to-reach groups is a currently underestimated issue that deserves a more prominent place in public health research. Frank J. van Lenthe REFERENCES 1. McDonald MP. United States elections project. Available at: http://www.electproject.org/ 2016g. Accessed November 9, 2016. 2. Cassino D. How today’s political polling works. 2016. Available at:
Leveraging Housing Vouchers to Address Health Disparities The Center for Medicare and Medicaid Services’ recently announced Accountable Health Communities (AHC) model aims to better integrate social needs into the clinical realm. Housing quality and insecurity is a core area that providers should screen for and address by linking beneficiaries with community service agencies. However, the effectiveness of the AHC model may be limited if there is a paucity of services to meet the needs that health care providers identify and if these services are not optimized to improve health. Changes in housing policy that better enable low-income families to live in low-poverty neighborhoods that promote health are critical in advancing the goals of the AHC model. Since the 1970s, housing policy has shifted away from
238
Editorial
Miles et al.
building housing developments toward providing vouchers that help pay the costs of private rentals. The Housing Choice Voucher Program (commonly known as Section 8 vouchers) helps more than two million low-income families secure affordable housing. When vouchers are used to help families move to low-poverty neighborhoods, they have been shown to improve health outcomes. The Moving to Opportunity for Fair Housing (MTO) experiment of the Department of Housing and Urban Development (HUD) was a decade-long randomized controlled trial involving the participation of 4600 families with children. By the end of the MTO study period, women who had received a voucher to move to a low-poverty neighborhood were less likely than members of
a control group to have diabetes and to be extremely obese.1 Although housing vouchers have been shown to provide essential support to the families that receive them, their effectiveness in offering access to more advantaged neighborhoods has been more limited. Only 15% of all children in families that receive vouchers live in lowpoverty neighborhoods (those with poverty rates below 10%), whereas 18% live in neighborhoods with the most extreme poverty (those with poverty
https://hbr.org/2016/08/how-todayspolitical-polling-works. Accessed November 8, 2016. 3. Mellon J, Prosse C. Missing non-voters and misweighted samples: explaining the 2015 Great British polling miss. Available at: https://papers.ssrn.com/sol3/papers. cfm?abstract_id=2631165. Accessed November 10, 2016. 4. Demarest S, Van der Heyden J, Charafeddine R, Tafforeau J, Van Oyen H, Van Hal G. Socio-economic differences in participation of households in a Belgian national health survey. Eur J Public Health. 2013;23(6):981–985. 5. Galea S, Tracy M. Participation rates in epidemiologic studies. Ann Epidemiol. 2007;17(9):643–653. 6. Gelman A, Goel S, Rivers D, Rothschild D. The mythical swing voter. Quart J Polit Sci. 2016;11(1):103–130. 7. Magn´ee T, Burdorf A, Brug J, et al. Equity-specific effects of 26 Dutch obesity-related lifestyle interventions. Am J Prev Med. 2013;44(6):e57–e66.
rates of 40% or more). Minority voucher holders are more likely than nonminority ones to live in these extreme-poverty neighborhoods.2 Multiple structural barriers prevent voucher recipients from renting in “opportunity” neighborhoods, defined as stable, low-poverty neighborhoods with high-performing schools, low crime and unemployment rates, and access to jobs. First and foremost, the supply of rental housing in these areas may be limited. Second, higher rents in more advantaged neighborhoods are unaffordable, even with assistance. In the voucher program, participants pay approximately one third of their income on
ABOUT THE AUTHORS D. R. Bailey Miles is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Barbara Samuels is with the American Civil Liberties Union of Maryland, Baltimore. Craig E. Pollack is with the Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine. Correspondence should be sent to Craig E. Pollack, MD, MHS, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E Monument St, Suite 2-519, Baltimore, MD 21287 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted November 4, 2016. doi: 10.2105/AJPH.2016.303565
AJPH
February 2017, Vol 107, No. 2
