· Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
The Supporting Healthy Marriages (SHM) is a yearlong program launched in 2003 that offers family strengthening education and service coordination to low-income married parents who have children or are expecting. The program uses group workshops, activities to strengthen skills built in the workshop, and additional support services to address participation barriers, connect families with other services, and reinforce program themes.
The program identifies common causes of significant psychological distress by targeting relationship coping skills, safety in relationships (including but not limited to psychological and physical abuse), stressors following addition of a new baby, and reducing adverse experiences for their children. These are all factors that have a huge impact on mental health, particularly depression and anxiety but also exacerbation of pre-existing mental illness. The psychological distress caused by lack of social support, marital conflict, and other relationship stressors are particularly damaging in low-income neighborhoods where social and financial support is lacking. Mental health in turn affects an individual’s ability to care for or seek care for one’s health and to the same for their children, in addition to the long-lasting health effects of psychological trauma for both children and their parents.
· Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
An evaluation of that policy could be crucial in determining the potential short-term and long-term social, economic,and health effects of an educational intervention targeting relationships and parenting. These are workshops and activities that are based on gaps identified in public health and social research, identifying successful programs based on such research could drive funding for and shift attention to the continued need for this type of research. It could also justify the need for more programs and social interventions in low income and disadvantaged neighborhoods, which pave the way for implementation of such programs on a larger possibly national scale. Finally it could shed light on the possible domino effect of educational and social programs that many might not equate with health outcomes.
· Specify the outcomes and populations you think most affected or least affected by the policy.
This program is specifically targeted to low-income and disadvantaged married couples with children or expecting children and will benefit most those lacking family or other social support, experiencing marital conflict, or mental illness. The outcomes of interest are couples’ relationship quality (but not stability) and stability, parenting, co-parenting, father-infant attachment, and infants’ language, emotional development and stability. With respect to the parents, the outcomes I believe will be most affected are self-reported measures of quality of life, measures of depression/anxiety, and of relationship satisfaction. With respect to the children, I believe the outcomes of academic performance and internalizing/externalizing behavior will be the most affected. However it is quite difficult to gage to what extent each will be affected, since many of these measures are the result of multifactorial processes that have not been directly targeted by this program. Moreover, it’s also important to distinguish between short-term and long-term effects, which in turn may be dependent on duration of the actual program.
· Propose a study design to evaluate the policy.
One study design to evaluate the child outcomes of this study could focus on cognitive and academic performance of the children of families enrolled in the program. We would study this at several school ages, since effects of the outcome could also vary according to child age. One way to do this would be by obtaining baseline scores of national standardized test (for each of the corresponding child ages) as well has high school graduation and college enrollment percentages. This could then be compared to the same measures taken at several timepoints during the program, at the completion of the program, and several years after completion of the program.
· Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
As described above, the greatest challenge is that the dynamics of relationships between policy and health outcomes on the population are multifactorial and have effects on several levels, the individual level, the community level, and the societal level. Moreover they are highly dependent on timing with respect to the age of the target population, the duration of the study, and the timing of outcome measurement. Disentangling such effects from potential confounders is a huge challenge, and might not even be achieved in many cases, but if we can identify even some of the significant effects, such analyses are worthwhile.