Friday, June 10, 2016

The Mysterious Connection Between Education and Health

Don Siegel

While youth development work involves many things, perhaps no outcome is more important than promoting health and well-being. Although, programs may or may not have components that most people associate with health promotion such as: physical activity, nutrition counseling, drug prevention, sex education, and violence avoidance, their support for educational attainment (years of schooling) is probably the single most potent factor in health promotion.  For many people this may appear to be a strange statement, as it would seem that directly addressing various health promoting or compromising behaviors would have the greatest “bang for the buck”, but a large body of research is showing that educational attainment is the single most important factor related to health across one’s life span.

Support for this contention comes from the many relationships that exist between education and markers of health. To get a sense of what I am writing about various studies have shown that people with more years in school have reduced morbidity from heart conditions, stroke, hypertension, elevated cholesterol, emphysema, diabetes, asthma, and ulcers.[1] As well, infant mortality rates are about half as large for mothers with 16 or more years of education than for mothers with 11 years or less. Educational attainment is also connected to longevity with college graduates living 5 years longer than individuals who have not finished high school (men – 79.7  vs. 72.9; women 83.5 vs. 78.4)![2]

Seemingly, such health outcomes could be mediated by a number of variables other than educational attainment, but evidence also exists that connects educational attainment to health promoting behaviors. For example, those with more years of schooling are less likely to smoke, to drink a lot, to be overweight or obese, or to use illegal drugs. Better educated individuals are also more likely to exercise and to obtain preventive care such as flu shots, vaccines, mammograms, pap smears, colonoscopies, to use seat belts, to have a house with a smoke detector and to have tested their house for radon.[3]

Again, while no one can definitively explain the causal connections between educational attainment, health behaviors, and health outcomes, a number of ideas have been advanced over the years that may mediate the relationships. These include, but are not limited, to the following:

1.     Environmental Argument: More education typically leads to greater incomes, which, in turn, provides more control over where one lives. Neighborhoods are associated with such things as housing quality, safety, proximity to supermarkets, access to recreation, availability of health providers, and the quality of air and water. Along with the physical environment, health is linked to the social environment in a neighborhood. Neighborhoods in which residence have stronger bonds have been shown to be places in which residents are more likely …to work together to achieve common goals such as
cleaner and safer public spaces, healthy behaviors and good schools; to exchange
information regarding childcare, jobs and other resources that affect health; and to
maintain informal social controls discouraging crime or other undesirable behaviors
such as smoking or alcohol use among youths, drunkenness, littering and graffiti—
all of which can directly or indirectly influence health.[4] Another version of the environmental contention is that more highly educated people get “better” jobs that, in addition to paying higher incomes and providing health insurance, offer safer work environments. In essence, this stream of thinking connects education with jobs, which are invariably connected with income and, in a variety of ways, with the environments that people either chose or a forced to live in. While researchers contend that the linkages between environment and health are complex, with research still to be done, they also assert that the overwhelming evidence is that the physical and social environments in which people live are strong predictors of their health, and that income, which is largely determined by education, is a critical factor in where people chose to live.

2.     Social Networks: Another aspect of the social environment is the support one gets from people around them. More educated persons have been shown to have larger social systems for financial, physical and emotional support.  Peer approval/disapproval can also effect whether one engages in high-risk behaviors. Thus, this theory contends that if more educated people associate with more educated friends, who are more likely to behave healthily and value health, the peer effects of networks will self propagate.  This does not only relate to adults, but to children whose social network includes their parents. Indeed, the connection between a parent’s education and their child’s health is very strong. Consequently, the education-health connection has a cross-generational-cascading effect in which more educated parents have healthier children, who, in turn become more educated and are healthier. They, in turn, live in healthier neighborhoods and associate with others who value healthy behaviors. Here, education, income, and social networks are interconnected, and are directly related to the subcultures that emerge. One need only observe the prevalence of parks, fitness clubs, supermarkets promoting organic foods, fast-food restaurants, and liquor stores in a community to get a sense of what it values with regard to healthy lifestyles.

3.     Future Optimism:  If education leads to higher income, greater control over one’s life, and generally improves one’s outlook on the future, individuals may be more likely to behave in ways to protect that future. On the other hand, less educated individuals may engage in riskier behaviors since the value of living to an advanced age is lower, and probably seen as less likely. Here, a psychological perspective that perceives a future filled with success and happiness, logically leads to a desire to protect one’s current and future health. On the other hand for folks living under duress, and who see little likelihood for change, the opposite may be true. As Bob Dylan’s song Like a Rolling Stone proclaims, When you ain't got nothing, you got nothing to lose. With little to lose, engaging in an array of health compromising activities may provide instant gratification, but do so at the expense of longer-term health. Thus, more or less education is connected to investing or not investing in one’s future, and a more or less hopeful future determines whether or not one engages in health enhancing or health compromising activities.
[5] 

4.     Information and Cognitive Skills: This idea connotes that more educated people are better informed, and, thus, make use of health related information to a greater extent than less educated individuals. For example, people with more years of education were more likely to quit smoking after the Surgeon General’s 1964 report that definitively linked smoking with lung cancer. It is also hypothesized that persons with more years of education have a greater awareness and understanding of modern ideas about nutrition, exercise, drug and alcohol abuse, and the most effective ways to manage diseases. Another variation on this theme is that more educated persons may not only be more aware of recent information about health, but also have greater regard for scientific findings, and, thus, be more willing to change their behavior accordingly. Higher educational attainment may also be connected to developing higher-level critical thinking and decision skills, which are essential to the regulation and control of behavior.

In summary, it is evident that health is intricately and powerfully connected with educational attainment. While the connections are complex, the emerging picture seems to reveal that educational attainment impacts such things as future income, which effects many of the choices that people can make about their lives including where they live, who they associate with, and how they think about their futures. Education also affects the access that people have to information, how they think about current health issues, and their willingness to act rationally to enhance their lives. Of critical importance is how the educational attainment of a parent affects their children with regard to a child’s own educational attainment, and the concomitant health benefits that accrue from such. So it appears that youth development programs that include activities such as sports, nutrition, violence prevention, and drug education are serving an immediate need to get kids on track to live healthy lives. To sustain these efforts, educational attainment is critical, and those programs that support the educational success of their participants are doing work that is truly transformative when considering their future health and well-being.



[1] http://www.nber.org/papers/w12352.pdf
[2] http://www.rwjf.org/en/culture-of-health/2012/08/better_educationhea.html
[3] https://www.cdc.gov/media/releases/2012/p0516_higher_education.html
[4] http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70450
[5] http://www.nber.org/papers/w12352.pdf

Thursday, May 19, 2016

What does Project Coach Cost in Comparison to Other Out-of-School Programs?


 Don Siegel


While questions relating to the actual or potential benefits accruing to participants in youth development programs can be difficult to answer at any particular point in time, the question of costs is of immediate interest to those involved in starting, scaling, or funding a program. Although the cost question seems fairly straight forward, it really is a bit more complicated than most people would think. Granting that actual cash expenditures for operations are included in all analyses, things get a bit trickier when trying to estimate the value of in-kind contributions, the use of free or reduced-cost facilities, or how to value the time and expertise of volunteer advisers, tutors and mentors. As well, programs also vary with regard to the breath and depth with which participants engage. Some programs are designed to take large numbers of youth who are provided minimum dosage and supervision, while others take a much smaller number of participants, but who are provided many hours of guidance in a smaller number of activities. This breath-depth variation also plays a role in computing and understanding a program’s cost. 

Nonetheless, having acknowledged the difficulties of computing costs, the Wallace Foundation[1] made an effort to do so, and to provide some benchmarks. Given the “apples and bananas” nature of such analyses, they examined the costs for 111 high quality programs located in six cities (Boston, Charlotte, Chicago, Denver, New York and Seattle). High quality was defined as programs having a high attendance rate (averaging 79% or greater), a high staff/youth ratio (averaging 1:8.3 or better), highly qualified staff (based on educational attainment and training - 30+ hours), and having leadership opportunities for older youth. Included in calculations were: staff salaries and benefits, space and utilities, administrative support, transportation, student stipends, and miscellaneous (snacks, meals, materials, staff training, etc.). Although their sample contained programs varying in size, focus, content, age groupings, location, staffing, ratio of staff to children, facilities, in-kind contributions, management and hours of operation, they did acknowledge that the sample was nonrandom, and that one must be careful when using their data to generalize to the universe of Out-of-School programs.

Cross tabulating programs by whether they were primarily for elementary students (ES), high school students (HS), or middle schools students (MS), they produced the estimates found below. On average, the cost of programs for elementary students (ES) was $6/hr. per slot[2], for high school students (HS) $10/hr., and for programs that had ES, middle school (MS), and HS students it was $9/hr. For programs that were solely focused on academics, the average slot cost was $12/hr. Ranges from the 25th to 75th percentile for each program category are also included.


Wallace (Slot Costs)
Range (25th to 75th percentile)
ES/MS Students Only
$6/hr
$2-$7/hr
HS
$10/hr
$4 - $12/hr
ES,MS,HS
$9/hr
$5 - $12/hr
Academic Focus
$12/hr
$5-$12/hr








Where does Project Coach Fall in this Matrix?

Given these values, I was wondering how Project Coach fared when compared to these estimates. Using a similar algorithm as that used by the Wallace Foundation, I estimated slot costs/hour of Project Coach to be $7.03[3]. This falls on the lower end of the range ($5 - $12) for programs with ES, MS, and HS students, and significantly less than the $9 average computed in the Wallace Database. While Project Coach seems relatively inexpensive compared to other programs, a likely reason for this is that, in contrast to the Wallace Foundation that found staff salaries, administration, and benefits to represent approximately 70% of a programs budget, staff salaries, administration, and benefits in Project Coach represent only 36% of the budget. As well, in the Wallace database space and utilities represented 13% of budgets, while in Project Coach space and utilities are in-kind contributions from Smith College and the Springfield School Department. As an aggregate, we see that collaborating with a college, and the school department in which a program is embedded can offset many expenses.

In computing costs, one can always jump to the conclusion that less expensive also means lesser quality. But, Wallace also compiled a list of nine indicators of quality. Many of these indicators have to do with staff training and evaluation, and the ratio of staff to youth. Using these criteria, Project Coach fared quite well. For example, staff meetings take place at least twice a month”. Project Coach has one or more staff meetings each week. Another guideline is that staff members are referred to training sessions. Project Coach has one or more training sessions each week. Guideline 8 states that programs operate with a low-staff-to-youth ratio (less than or equal to 1:10). In Project Coach the ratio of staff to HS students is 1:3[4], and for ES it is 1:3.5[5].

While it is true that variability across programs makes direct cost comparisons inexact, doing such an analysis provides greater understanding about how a program’s dollars are being spent, and how in-kind contributions can off-set out-of-pocket expenses. This brief analysis of Project Coach shows that it is a relatively lower cost program, that also meets the standards of high quality. Yet, it also shows that a large part of it’s cost effectiveness results from it collaborating with Smith College and the Springfield School Department. 


For those interested in estimating the cost of a program the Wallace Foundation provides a cost estimator calculator at http://www.wallacefoundation.org/cost-of-quality/pages/default.aspx.






[1] http://www.wallacefoundation.org/knowledge-center/after-school/key-research/Documents/The-Cost-of-Quality-of-Out-of-School-Time-Programs.pdf
[2] Slot cost/hour is a standard metric used by researchers who compute program costs. It is the cost of serving one more youth over the course of a program schedule (e.g., having an average daily attendance—ADA—of 101 versus 100). Cost per slot is calculated by dividing the total cost by a program’s ADA.
[3] I used 90% attendance for MS/HS participants and 80% attendance for ES students.
[4] This ratio goes to 1:1 when HS students are tutored by Smith College Students.
[5] This low ratio is a result of MS/HS students being considered staff when tutoring and coaching ES students.

Monday, February 1, 2016

Project Coach and Community Development

Don Siegel


One of the most fascinating social experiments of the last quarter century has been the government’s Moving to Opportunity Program (MTO). In a nutshell, the Department of Housing and Human Development (HUD) ran an experiment during the period 1994-1998 to determine the effects of living in neighborhood’s varying in prosperity on the economic fortunes, and the heath and well-being of poor families. Neighborhoods differing on average income also differ on such things as, quality of housing, social cohesion, family structure, safety, employment opportunities, prevalence of parks and playgrounds, school quality, access to healthful foods and health services, and the presence or absence of such things as gangs, violence, and drugs. Given the array of factors that differentiate wealthy from poor communities, a general hypothesis upon which this experiment was based is that where one lives will largely determine what one becomes.
The way the experiment worked was that from 1994 to 1998 HUD awarded housing vouchers to 4604 low-income families living in high-poverty neighborhoods in five cities. Most heads of households in this experiment were African-American or Hispanic females who had less than a 40% high school graduation rate. As well, a large percentage indicated that they had signed-up for the MTO initiative because they wanted to leave gang and drug infested neighborhoods.

What made this experiment unique was that families were randomly assigned to one of three groups:
·      Group 1 received a housing voucher, which restricted them to relocating to a low poverty neighborhood (poverty rates below 10%).
·      Group 2 received a housing voucher that had no restrictions on where it could be used.
·      Group 3, which could be thought of as a control group, just received housing assistance in the projects where they currently lived.
The ultimate question was what effects, if any, a poor family experienced if they relocated to a neighborhood inhabited by more affluent cohorts.

Results

Surprisingly, after 15 years, no economic differences were found for adults moving to a more affluent community. That is to say, income was approximately the same whether or not an adult moved to a wealthier community or stayed in a poorer community. As well, only marginal, but non-significant differences were found in the physical and mental health of adults who had relocated. Clearly, the lack of effects on these important variables were not what HUD had hoped for when they crafted MTO.

However, these findings, or lack of findings, may not tell the whole story as a somewhat curious measure of self-reported well-being did show that, despite non-significant results in what might be conceived as more substantive measures, adults who moved to less distressed neighborhoods perceived themselves to be happier and better off. While it is always a bit speculative to quantify psychological states in economic terms, a recent study stated that such a psychological profile was typical of people earning an additional $13,000.[i] In a sense then, poorer adults were receiving a real increment in their psychic income from living in a wealthier neighborhood that was not associated with an increment in their real income.

This gets even more interesting as another, more recent study, examined what happened to the children who were part of the various MTO groups by the time they got to their mid-twenties and older.[ii] Results showed a clear dosage effect. Children who were less than 13 (average age 8) when they moved to a wealthier neighborhood, who had had 9.8 years, on average, of exposure, earned $3477 more a year than controls, were more likely to attend college (16% better than controls), attended better colleges, were also more likely to live in lower-poverty neighborhoods as adults, and less likely to be single parents themselves. On the other hand, children who moved to wealthier neighborhoods between the ages of 13-18 (average age 15), were associated with negative effects. By their mid-twenties they actually earned $967 less per year than controls, and fared poorer than or equal to controls on other things such as college attendance, college quality, where they lived as adults, and whether they were single parents themselves as adults. Consequently, it appears that MTO had different effects depending on when a child moved. For younger children, the effects were positive. For older children, they were negative. While explaining such differential effects can only be speculative, arguments have been made that positive effects for younger children were a result of exposure to positive experiences over a longer period during critical developmental years. On the other hand, negative effects for older children have been attributed to the disruption of social networks that are critical during the adolescent years.

What does MOT Mean to Programs such as Project Coach and Community Development?

From a wider perspective, moving to a lower poverty neighborhood, had consequential long lasting effects on younger children that were transferred, in turn, to their own children. More so, the effects do not appear to be mediated by family income, but by a neighborhood’s economic well-being, which, in turn, has an impact on an array of environmental factors. While the data are clear that MTO has a powerful effect on changing younger children’s lives, and the lives of their children, it is not clear on what specific neighborhood factors were responsible for producing different life trajectories for these children. Seemingly, if these could be identified and transported across neighborhoods, we might anticipate better life outcomes for youth growing up poor.

Given that our government is not about to provide housing vouchers for millions of poor families to relocate to more affluent neighborhoods, it seems reasonable to ponder how those things that poor families experienced in wealthier neighborhoods can be replicated in poorer neighborhoods. Clearly, this seems like a reasonable question to ask, but those of us who do community work every day know that it is not easily answered. Communities are complex places, and the term emergent system, seems to characterize such geographical enclaves.  In short, healthy neighborhoods require many ingredients that interact in complex ways. In such a system, the sum of interactions is greater than all of its parts. Furthermore, no one really knows how, or is able, to build the ideal community from a well-defined blueprint over which they have the capacity to control inputs and outputs.

Yet, experiments like MTO appears to be telling us that children are impacted by where they live and grow-up, that effects are cumulative, and track into adulthood. While clarity does not exist on which factors are most critical to the neighborhood effect a simple message may be that many components are part of the mix, and that neighborhoods that wish to be transformed need to work on anything and everything. These should include, but not be limited to such things as: (a) physical aspects, which would comprise the quality and maintenance of housing, parks, libraries, and other public spaces; (b) the quality of schools, (c) the availability of medical services; (d) easy access to supermarkets that carry a wide variety of foods; (e) safety in the streets and on playgrounds; (f) support for businesses that provide goods, services, and employment; and  (g) promoting social cohesion that engages citizens in community decisions about things that affect their lives.

Within this context, programs such as Project Coach play a critical role. While not the universal panacea for all the challenges that distressed neighborhoods face, it is an important ingredient that goes into the stew of factors that can make a community more livable.  Project Coach on face value may be viewed as a sport’s program, but by design sports are simply the medium through which youth are engaged so that they can build: (a) relationships between young children who get opportunities to play various sports and adolescents who serve as their coaches and mentors, (b) relationships among adolescents and their young adult mentors and tutors who help them to meet the daily challenges of growing up in an underserved community, and (c) lifeskills and character skills that help youth to achieve the same sorts of things that the younger children in MTO achieved. Project Coach also provides a means for bringing children’s parents and other relatives together to observe them in action, and for parents to participate together with their children in various activities during monthly community nights.

Surely, Project Coach, or any other program alone, does not contain the full array of benefits that children obtained from MTO, but it is the type of ingredient that can be added into the stew that ultimately makes a neighborhood a better place to live. Clearly, the MTO voucher program makes sense, but for the vast majority of families who will never see a voucher and continue to live in poor neighborhoods, we should continue to offer residents programs, like Project Coach, that make where they live a bit more like the places to which MTO families moved. 




[i] Ludwig, J., Duncan, G. J., Gennetian, L. A., Katz, L. F., Kessler, R. C., Kling, J. R., & Sanbonmatsu, L. (2012). Neighborhood effects on the long-term well-being of low-income adults. Science, 337, 1505-1510.
[ii] Chetty, R., Hendren, N., & Katz, L. F. (2015). The effects of exposure to better neighborhoods on children : New evidence from the moving to opportunity experiment Cambridge, Mass. http://scholar.harvard.edu/files/hendren/files/mto_paper.pdf.