Evidence Briefs: Public Health Topics
Systematic Reviews
The Problem:
Tuberculosis is a classic public health scourge. Globally, there are over 9 million new cases of TB each year. World Health Organization: Tuberculosis Fact Sheet. The risks associated with TB have increased with the emergence of more virulent and drug-resistant strains of the disease. In the United States, the rate of TB incidence and associated mortality declined precipitously for most of the 20th century. In 1900 TB was the second leading cause of mortality accounting for over 10% of deaths; by 1980s deaths attributed to TB were in the hundreds. CDC: MMWR: Achievements in Public Health: Infectious Disease. In the early 1990s, however, incidence of TB began to increase again due to the HIV/AIDS epidemic and the synergistic risks of co-infection. Although these increases appear to have leveled off in the last few years, the risks associated with drug resistant strains continue to make TB an important public health challenge. CDC: MMWR: Trends in Tuberculosis.
The Law:
There are numerous legal measures for controlling the spread of TB. Law authorizes surveillance and specifies treatment requirements like Directly Observed Therapy (DOT). The most extreme and controversial legal measures involve the involuntary detention of individuals who are suspected or known to have infectious TB. In the United States, state statutes (Ca. Health & Safety Code § 121366) and regulations (New Jersey, N.J. Admin. Code § 8:57-5.7 et seq) define the procedural and substantive requirements for detaining an individual who presents a putative risk to the community as the carrier of an infectious disease. A sizable body of case law has also developed providing guidance about how and when an individual can be detained against their will to protect the public from disease. One of the seminal cases interpreting state power over coercive tuberculosis control measures is Green v. Edwards, 263 S.E. 2d 661 (1980).
The Evidence:
Coker systematically reviewed studies assessing the effect of detention of individuals with TB on public health. R.J. Coker. Public Health Impact of Detention of Individuals with Tuberculosis: Systematic Literature Review. Public Health (2003) 117, 281–287. Twenty-two studies fit the inclusion criteria. One of the studies employed a molecular finger printing design and found evidence that removing some infected individuals from the population would significantly decrease population incidence. Other modeling studies, however, suggested that the presence of coercive measures might increase transmission by decreasing the proportion of infected individuals that seek treatment. Observational and case control studies were few and small. According to Coker, there is insufficient evidence to sustain inferences about the effects of detention on population health.
The Bottom Line:
According to the author of a peer-reviewed systematic review, there is insufficient evidence at this time to conclude that detention of individuals with infectious tuberculosis improves population health.
The Problem:
Illicit drug use is a well-recognized public health problem. Overdose and other less acute harms are associated with the non-medical use of controlled substances. The policy response to illicit drug use in the United States has historically focused on a punitive model. Resulting high rates of incarceration have placed large numbers of non-violent offenders into correctional facilities. Life in prison exposes inmates to numerous health risks. High incarceration rates also strain families and communities particularly in areas already suffering from harms associated with low socioeconomic status. As a result, both illicit drug use and the prevailing policy response aimed at reducing it are sources of harm to population health. Reducing incarceration for non-violent crime – the majority of which involves use and trafficking of small amounts of illicit drugs – is widely recognized as an important policy objective. Congressional Research Service, GAO: Drug Courts.
The Law:
In response to growing evidence of the public health burden of over-criminalization and the failure of the traditional punitive approach to stem illicit drug activity, in the late 1980s, states and localities started experimenting with models aimed more at rehabilitation than retribution. Representing one form of what is often referred to as therapeutic justice, drugs courts emerged as a new model for dealing with minor drug-related crimes. These specialized courts aim to divert convicted drug-offenders into treatment rather than incarceration. Between 1989 and 2009, well over 2000 drugs courts were created in the United States. U.S. Department of Justice. Many drug courts are created though judicial rulemaking. Examples of laws creating drug courts can be found in Mississippi (M.S. Code § 9-23 et seq) and Illinois (730 ILCS 166.1 et seq).
The Evidence:
Wilson, et al., systematically reviewed studies assessing the effect of drug courts on recidivism. David B. Wilson, Ojmarrh Mitchell, And Doris L. Mackenzie, A systematic review of drug court effects on recidivism, Journal of Experimental Criminology (2006) 2:459Y487. The reviewers identified fifty studies that fit their inclusion criteria. Using meta-analytic techniques, the reviewers combined odds-ratios across the studies in a random effects model. The overall summary odds ratio – which was statistically significant – was 1.62. The reviewers’ interpretation of the results from the summary statistic and other correlates in the regression was that recidivism decreased by 26% for offenders in drug courts versus comparison groups. However, methodological weaknesses in the majority of the included studies were noted as a source of caution against this figure. A more conservative estimate of the effect was found when they limited their review to more methodologically sophisticated studies. Overall, however, the authors view the evidence as sufficient to support the effectiveness of drug courts in reducing recidivism.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is sufficient evidence to support the effectiveness drug courts in reducing recidivism among individuals convicted of drug-related offenses.
The Problem:
Sexual abuse is a big public health problem. Every year, there are about 90,000 rapes. U.S. Department of Justice, Federal Bureau of Investigation. Victims of sexual abuse suffer extensive physical and emotional harms; the long term sequelae of sexual abuse are associated with a number of health risk factors later in life. Beitchman et al, A Review of the Long-term Effects of Child Sexual Abuse, Child Abuse & Neglect 1992; 16(1): 101-118. A significant portion of sexual crimes are committed by juveniles; research indicates that as much as 80% of adult sexual offenders committed sexual crimes as juveniles. Groth et al, Undetected recidivism among rapists, and child molesters. Crime and Delinquency, 1982; 128: 450-458. This suggests that treatment and rehabilitation of juvenile sexual offenders (JSOs) is important to reducing sexual violence. In 2008, 14,500 children were arrested for sexual offenses not including rape; 3340 children were arrested for rape. U.S. Department of Justice, Office of Juvenile Justice0. Rehabilitation is the primary aim of juvenile criminal justice systems in the United States. However, high rates of recidivism in sexual crimes and the high proportion of sexual crimes committed between juvenile family members challenge policies that otherwise seek to minimize the time that juvenile offenders spend in correctional custody. In this context, JSOs often fail to receive treatment addressing the bio-psychosocial causes of offending.
The Law:
Mandatory treatment is often required as a condition of adjudications or plea bargains for juveniles charged with sexual crimes. The court system presents, in this respect, an important source of leverage for forcing sexual offenders into treatment. Probation and sentencing contingencies may be used to increase compliance with mandated treatment. All judges have discretionary authority to order participation in treatment programs for minors in adjudications involving sexual crimes. Some states mandate treatment in specialized programs for juvenile sexual offenders (Kentucky, KRS 635.515 (1), Alabama, Ala. Code 15-20-27).
The Evidence:
Reiztel and Carbonell conducted a systematic review and meta-analysis of studies evaluating the effectiveness of juvenile sexual offender treatment programs. Lorraine R. Reitzel and Joyce L. Carbonell, The Effectiveness of Sexual Offender Treatment for Juveniles as Measured by Recidivism: A Meta-analysis, Sex Abuse (2006) 18:401–421. Only studies comparing recidivism among groups receiving and not receiving treatment were included; random placement into treatment and control groups was not required. Nine studies satisfied the inclusion criteria. Using a fixed effects meta-analysis of odds ratios across the studies, the reviewers found a statistically significant 0.43 effect size suggesting a sizable protective relationship between treatment and recidivism: for every 43 offenders in the treatment group that recidivate, 100 in the control group do so. Simple un-weighted average recidivism rates between the treatment group (7.37%) and the control group (18.93%) were substantially different. Though cautioning that the treated and untreated groups may have varied in systematic ways, the authors viewed the nine studies as sufficient evidence to conclude that treatment is effective in reducing recidivism.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, there is sufficient evidence to support the effectiveness of laws requiring treatment for juvenile sexual offenders in reducing recidivism.
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion in annual lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Initiation of smoking and other tobacco use generally starts in adolescence; more than 80% of adult smokers started smoking as young children or teenagers. CDC: Youth Tobacco Use Fact Sheet.
The Law:
Pursuant to the 1997 federal “Synar law” states must prohibit the sale of tobacco products to children and take steps to ensure effective enforcement. 42U.S.C. 300x-26, 45 C.F.R. 96.130. States and localities have adopted numerous legal interventions to increase compliance with this prohibition. For example, some states prohibit the handling of tobacco products by minors working in retail and require posting of signs explicitly prohibiting sale of tobacco products to minors (Oklahoma, 37 O.S. §600.1-§600.12). Under age purchasers of tobacco face fines and community service (Washington, RCW 70.155.080). To increase compliance with youth access laws, localities and states also conduct compliance investigations (Missouri: Restricting Youth Access to Tobacco).
The Evidence:
Stead and Lancaster systematically reviewed studies assessing the effect of laws restricting youth access to tobacco and interventions aimed at increasing compliance with youth access laws. Lindsay F Stead and Tim Lancaster. A systematic review of interventions for preventing tobacco sales to minors. Tob Control 2000 9: 169-176. The reviewers identified 27 studies that fit their criteria of employing either experimental or observational designs with data both before and after the adoption of a law or compliance intervention. The studied laws included requirements for compliance checks; the evaluated interventions included experiments with compliance checks and education campaigns with retailers about fines and enforcement of youth access laws. Most of the included studies found reductions in prevalence of smoking among youths or decreases in reported ease of purchasing tobacco for minors. Although the reviewers were cautious because of methodological limitations in the studies such as the inability to control for potentially confounding effects from other youth smoking prevention programs and the possibility that effects wane over time, they view the collective body of studies as sufficient evidence to conclude that laws restricting youth access and interventions aimed at increasing compliance do indeed reduce access to tobacco for minors. The reviewers observed that greater levels of compliance activity – such as personal visits to retailers – were more likely to result in greater reductions in smoking or access.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is sufficient evidence to support the effectiveness of youth access laws and interventions aimed at increasing compliance as a means of decreasing access to tobacco for minors.
The Problem:
Medical injuries are widely recognized as one of the top ten leading causes of mortality in the United States. In 2000, the Institute of Medicine found that between 44,000 and 98,000 Americans die each year from avoidable medical errors. Institute of Medicine. More recent research suggests that more than 13% of hospitalized patients suffer an adverse event resulting in serious harm and that 44% of those events are preventable. The cost of these preventable harms is huge surpassing hundreds of millions of dollars each month. Department of Health and Human Services, Office of the Inspector General. One factor that has attracted attention as a plausible cause of medical error is long work hours for healthcare workers and especially resident physicians. In is not uncommon for residents and other emergency room physicians to work in excess of 100 hours a week. Such shifts raise questions about the influence of fatigue on medical decision-making.
The Law:
Medical care in United States is regulated primarily at the state level through professional organizations. Most regulation of work hours has been by state law. New York, for example, limited medical resident work hours in 1989 through regulations (NY Comp Codes R & Reg. Title 10 § 405 (1989)) often referred to as the Libby Zion law in honor of a child whose death was attributed to alleged mistakes by an overworked medical resident. Educational accreditation bodies, like the Accreditation Council for Graduate Medical Education (ACGME), also set requirements for residency programs. In 2003, for example, ACGME limited to 80 the number of hours that residents could work per week on average over a four week period. Report of the ACGME Work Group on Resident Duty Hours. These restrictions do not apply to health care workers that are not medical residents.
The Evidence:
Fletcher et al conducted a systematic review of studies evaluating the effectiveness of restrictions on HCW work hours aimed at improving patient care. Fletcher et al, Systematic Review: Effects of Resident Work Hours on Patient Safety, Ann Intern Med. 2004;141:851-857. The reviewers identified seven studies that met their inclusion criteria. The results of the studies were inconsistent across a number of measures and none provided statistically significant evidence that patient outcomes improved subsequent to limitation of healthcare worker hours. The reviewers note that while experimental and bio-psychosocial evidence supports a positive causal relationship between fatigue and diminished performance by healthcare workers, patient outcomes are also influenced by continuity of care. The reviewed studies provide some evidence that the benefits of reduced fatigue are offset by disruption in the care that healthcare workers provide due to the shortening of shifts. Overall, the reviewers did not find conclusive evidence supporting the effectiveness of laws limiting work hours as means of improving patient outcomes.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is insufficient evidence to currently support the effectiveness of restrictions on healthcare worker hours in improving patient outcomes.
The Problem:
Firearms are the second leading cause of injury and deaths in the United States, accounting for 30,896 deaths and 71,417 injuries in 2006. More than 80 percent of teen homicides and almost half of teen suicides involved a gun in 2005. CDC: WISQUARS. More than half of all homicides involve a gun. U.S. Department of Justice: Crime Statistics.
The Law:
Much of the burden of gun violence and accidental gun injuries falls upon localities. As a result, localities have been at the vanguard of efforts to find new legal approaches to reducing the harms of unsafe gun practices. Some of these strategies – like local bans on gun possession and efforts to regulate gun retailers under public nuisance laws – have been overturned by courts. As a result, few localities in the United States currently have the authority to pass gun control legislation that address gun safety. Localities do, however, have significant latitude in how they enforce existing gun control laws. Law enforcement strategies for reducing the illegal possession of guns include directed patrols aimed at uncovering and deterring illegal gun possession in specific high risk areas.
The Evidence:
Koper and Mayo-Wilson systematically reviewed 4 studies that assessed the impact of directed patrol law enforcement strategies for decreasing gun-related crimes. Koper & Mayo-Wilson. Police crackdowns on illegal gun carrying: a systematic review of their impact on gun crime. Journal of Experimental Criminology 2006; 2:227-261. The four studies reported on a total of 7 nonrandomized tests. In 6 of the tests, directed patrols were associated with reductions in firearm crimes. Notwithstanding the small number of studies and limited study designs, the authors interpreted the review findings as evidence that directed patrols reduced gun crime in high-crime areas.
The Bottom Line:
According the authors of a peer-reviewed systematic review, there is strong evidence supporting the effectiveness of directed patrols as an intervention aimed at reducing gun-related crime in high risk areas.
The Problem:
Motor vehicle accidents are one of the largest sources of public health harms. For people ages 1 to 34, motor vehicle crashes are the number one cause of death. Almost five million people each year suffer injuries during motor vehicle crashes that require emergency care. CDC Fact Sheet: Motor Vehicle Safety. Adverse weather conditions including snow and ice contribute to the incidence of motor vehicle crashes. Some evidence suggests that studded tires reduce accidents in inclement weather by providing better traction for motor vehicles. Studded tires are also known to damage road surfaces.
The Law:
States have the authority to ban or limit the use of studded tires. Some ban all studded tires, see Fl Rev Stats 316.299 (Florida), 9 ID Statutes 49-948 (Idaho), and Wisc. Trans Code 306.01 (Wisconsin). Other states have enacted seasonal limitations on their use, see 90 MGL 60 (Massachusetts), Ca Vehicle Code § 27454 (California), 67 Pa. Code. § 175.80 (Pennsylvania) and OH R.S.5589.081 (Ohio).
The Evidence:
According to the author of a peer-reviewed meta-analysis, laws banning studded tires result in small increases in motor vehicle crashes during winter months. Elvik. The effects on accidents of studded tires and laws banning their use: a meta-analysis of evaluation studies. Accident Analysis & Prevention 1999; 31:125-134. Of the 7 studies that Elvik identified as meeting the inclusion criteria, two were based in the United States, one in Canada, one in Germany and three in Japan. Six of the studies found that laws banning studded tires were associated with small increases in accidents during winter seasons. A meta-analysis revealed a weighted mean increase in winter accidents of 4 percent. This finding is consistent with meta-analysis results in the same review indicating that actual studded tire use reduces accident rates during winter.
The Bottom Line:
According to the author of a peer-reviewed meta-analysis, the evidence suggests that banning studded tires causes a small increase in motor vehicle accidents during the winter.
The Problem:
In 2006, approximately two-thirds of adults and one-fifth of children in the United States were either overweight or obese. Each condition increases the risk of heart disease, diabetes, stroke, and some cancers. Kahn LK, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR 2009;58(RR-07):1-26. Regular physical activity reduces the risk of obesity and has many other health benefits. Yet, only 25 percent of adults in the United States get the recommended amount of physical activity. CDC. Community interventions to promote healthy social environments: early childhood development and family housing. MMWR 2002;51 (RR-1):1-8.
The Law:
Some local governments have attempted to promote exercise at the community level through careful modifications to zoning regulations and building codes. These efforts involve, for example, locating commercial stores, places of work, or schools within walking distance of residential communities to facilitate commuting by foot or bicycle. For example, a Sacramento Ordinance available at the California Healthy Eating Active Living Cities Campaign sets out zoning standards to ensure that streets provide ample space for walking and bicycling. The National Policy and Legal Analysis Network to Prevent Childhood Obesity (NPLAN) has created model “complete street” state laws and ordinances, which are aimed at creating safe environments for walking, jogging and other non-vehicle commuting.
The Evidence:
Heath et al. reviewed 12 studies that measured the impact of community-scale urban design and land use policies on levels of physical activity. Heath G, et al. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. Journal of Physical Activity and Health. 2006;3 (Suppl 1):S55-S76. The authors limited their review to studies that focused on physical activity outcomes, measured by incidence of walking or biking for transportation as well as overall physical activity and outdoor active play. The reviewers found evidence that community level urban design and land-use policies increase physical activity. Across all studies, there was a 161 percent median improvement in at least one measure of physical activity (e.g., number of walkers or bicyclists).
The Bottom Line:
According to a Community Guide expert panel, there is considerable evidence supporting the effectiveness of community-scale urban design and land use policies as public health interventions to promote physical activity.
Additional Information:
For a short summary of research related to the importance of designing communities to promote health, refer to this research brief by Active Living Research (ALR).
The Problem:
Violence is a major public health problem. There were more than 5 million violent crimes in 2007, including 248,280 sexual assaults and 597,320 robberies. USDOJ: Criminal Victimization in the United States, 2007. There were 16,272 deaths from murder or non-negligent manslaughter in 2008. U.S. Bureau of Justice Statistics. In addition to directly causing acute injuries, emotional harm, and deaths, crime may undermine population health through indirect mechanisms. For example, high rates of crime make outdoor exercise unsafe, contributing to lower levels of physical activity. Crime also adds to the burden of stress for people living in high crime areas.
The Law:
The law prohibits violent crime, but implementation varies. “Hot spot policing” is a law enforcement strategy that focuses limited police resources on street corners, alleys or other places in a neighborhood where crime is particularly prevalent. For more information on hot spot policing, see U.S. Dept of Justice: Hot Spot Policing.
The Evidence:
Braga systematically reviewed nine studies that assess the impact of hot spot policing on crime. Braga. The effects of hot spots policing on crime. Campbell Systematic Review 2007:1. The studies evaluated three types of hot spot policing interventions: (1) enforcement of problem-oriented policing interventions; (2) directed and aggressive patrol programs; and (3) police crackdowns and raids. Of the nine studies, five employed randomized experimental designs and four employed quasi-experimental designs. Seven of the nine studies found hot spot policing to be associated with reductions in crime and disorder. A meta-analysis conducted on the five randomized studies found a statistically significant 67 percent reduction in reported calls for police assistance. There was not enough evidence to determine the relative effectiveness of the three different intervention types. Displacement of crime – a concern with hot spot policing – was examined in five of the studies. None of the studies observed a substantial displacement effect. However, Braga and the authors of the underlying studies caution that displacement is a difficult phenomenon to measure and that more sophisticated measures may be needed to fully assess whether displacement occurs. Braga interpreted the results of the meta-analysis of the five studies and the evidence in all nine studies collectively as “fairly robust evidence that hot spots policing is an effective crime prevention strategy.”
The Bottom Line:
According to the author of a Campbell Collaboration systematic review and meta-analysis, the current evidence supports the effectiveness of hot spots policing as a crime prevention strategy.
The Problem:
The maltreatment of children is a tragically common occurrence in the United States with a devastating impact on the health of young Americans. The direct effects of child maltreatment for victims include injuries and a host of stress-induced harms including poor psychological health, obesity, eating disorders and suicide. Child maltreatment also indirectly harms public health by creating generational cycles of abuse; a significant portion of victims of child abuse become child abusers. In 2007, there were 3.2 million cases of child abuse in the U.S. Centers for Disease Control: Child Maltreatment Fact Sheet. While primary prevention strategies focus on identifying risk factors to stop child abuse before it occurs, establishing secondary prevention methods to limit the harms of abuse is also of great importance.
The Law:
Kinship care is a legal arrangement in which a child welfare agency places a maltreated child under the direct care of a family member or family friend with a suitably extensive pre-existing relationship with the child. The Personal Responsibility and Work Opportunity Reconciliation Act (1996) required states to give preference to family members when placing a child outside the home. 42 U.S.C. 671(a)(19). More recently, the Adoption and Safe Families Act (1997) reaffirmed the federal commitment and support for kinship care. Although states have adopted slightly different definitions of family and kin, kinship care is widely preferred among jurisdictions. For examples of kinship laws, see CA Welf. & Inst. Code § 361.3 (California) and CO Rev. Stat. §§ 19-3-508; 19-3-605 (Colorado).
The Evidence:
In a study sponsored by the Campbell Collaborative and also published in the Cochrane Guide database, Winokour et al. performed a meta-analysis on 62 studies that evaluated the well-being of children placed in formal kinship care versus those placed in traditional foster homes. Winokour et al. Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. The Campbell Collaboration. January 2009. Their analyses showed that children in kinship care have better mental health functioning, behavioral development and placement stability than children in non-kinship care. No differences were found in the rate of reunification with biological parents or in educational attainment. Children in non-kinship care also accessed mental health services and support groups slightly more than kinship care children, though it is unclear, according to Winokour et al., whether this benefit was the result of need or accessibility.
The Bottom Line:
According to a systematic review and meta-analysis sponsored by the Campbell Collaboration, kinship care placement produces better outcomes than non-kinship care for children that have been subject to maltreatment at home.
Additional Information:
The Children’s Bureau of the U.S. Department of Health and Human Services has compiled a guide on state kinship laws: Placement of Children with Relatives: Summary of State Laws.
© RWJF 2012
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Public Health Law Research is a national program of the Robert Wood Johnson Foundation. It is housed at the Temple University Beasley School of Law.