CHAS 2009-2010 Seed-Grant Awards

• E. Summerson Carr, PhD
• Jens Ludwig, PhD
• Jennifer Mosley, PhD
• Tomas Philipson, PhD

E. Summerson Carr
"Teaching, Translating, and Enacting Clinical Expertise: A Pilot Study of Motivational Interviewing"

The proposed project will investigate how Motivational Interviewing (or MI), an increasingly popular clinical intervention for changing substance abuse and other targeted health behaviors, is disseminated through training, and how that training affects the clinical practice of new trainees as they return to the complex sites where they do their work.  Using ethnographic methods, this project aims to open the “black box” of MI expertise to provide a nuanced understanding of how the specific techniques and the harder-to-quantify “spirit” of MI are transmitted and enacted in health and mental health service orgainzations. Such knowledge is of central concern to those interested in devising effective MI training strategies and to those more generally concerned with the dissemination of evidence-based practices and clinical practice models in health and mental health services. Comparing data generated by existing instruments (e.g., the Motivational Interviewing Treatment Integrity scale) with data collected through interviews, participant observation, and linguistic analysis of therapy transcripts, this study will be the first of its kind to systematically employ ethnographic research methods to evaluate MI in practice. A specific aim of this project is to contribute in-depth knowledge about how training functions in the dissemination of clinical innovations, as well as to larger interdisciplinary discussions of the production of clinical and professional “expertise.” More generally, in an effort to understand MI as a prevalent approach to health and mental health treatment, this project will assess current efforts to improve the quality of MI implementation, particularly in agencies that serve vulnerable populations.

Jens Ludwig
"Measuring Neighborhood Effects on Long-term Health Outcomes"

Health outcomes vary dramatically across neighborhoods in the United States, even after regression adjusting for observable characteristics of individual neighborhood residents. Yet the degree to which the associations reported in previous studies reflect a causal effect of neighborhoods remains uncertain because most families have some degree of choice over where they live, which means previous studies may confound neighborhood effects with those of hard-to-measure individual or family attributes associated with residential selection. Our project seeks to learn more about long-term neighborhood effects on health, and how to use large-scale social experiments to answer this question. The present proposal’s PI is the project director for the long-term (10 year) evaluation of a unique randomized housing voucher experiment by HUD called Moving to Opportunity (MTO), which enrolled a total of 4600 minority public housing families from five U.S. cities and via random lottery provides some the chance to relocate to less distressed areas with housing vouchers. Interim (5 year) evaluation results show important impacts of residential relocation on obesity, diet, and exercise. To better understand long-term neighborhood effects on health we have added dried blood spot (DBS) collection to the longterm evaluation data collection plan, which presents a more feasible way of measuring key disease precursors compared to using licensed phlebotomists to collect venipuncture blood samples. We request $10,000 in funding from CHAS for partial support of a blind validation study to document the ability of DBS collection and analysis to replicate gold-standard clinical analysis of venipuncture blood samples for measurement of biomarkers such as total cholesterol (TC), high density lipoprotein (HDL), Creactive protein (CRP), glycosylated hemoglobin (Hb1Ac), Epstein-Barr virus (EBV), and cortisol. This DBS validation study will substantially increase the scientific credibility of the long-term MTO health impact estimates and help guide measurement design in future studies.

Jennifer Mosley
"Improving Health Outcomes and Community Representation through Understanding Organizational Infrastructure in Neighborhoods"

The overall objective of this project is to improve health outcomes, community engagement, and representation through increased knowledge and collaboration with community-based organizations on the Southside of Chicago. An important key to doing this is discovering how formal and informal community-based organizations represent the views and concerns of residents. The overall project has three phases: 1) an organizational asset mapping, or census, in six Southside neighborhoods, 2) surveying a sample of those organizations in order to assess their strengths, capacity, and efforts to represent and engage community members, and 3) surveying a sample of residents in order to understand their usage patterns and perceptions of how well organizations represent their interests. Specific aims: This application requests support for pilot work on one portion of the larger project: the resident surveys. Pilot work is crucial for the resident survey for two reasons: we are asking questions that may be unfamiliar to residents, and anticipate that serious obstacles may exist in regards to achieving an adequate response rate. Thus, the primary aims of the research proposed here are to 1) use cognitive interviewing to produce valid and reliable survey questions for residents about how organizations represent their interests, and 2) conduct iterative pretests of the full survey, to further refine our process and ensure that residents are contacted in a way that is effective and encourages their participation. Relevance to CHAS objectives: Research on the social determinants of health has shown that residents of neighborhoods where access to resources is low have compromised health outcomes compared to those who reside in more asset rich neighborhoods. Understanding the strengths and weaknesses of the organizational infrastructure on the Southside of Chicago, as well as how residents perceive the usefulness and representativeness of those organizations, will assist in understanding how health outcomes on the Southside can be improved. Research design and methods: Twelve community members with diverse demographic profiles will be recruited to participate in cognitive interviews assessing their understanding of a bank of possible questions. These interviews will be used to refine the questions and ensure that the intent of the questions is understood by community members. Once valid and reliable questions have been produced a series of 10 iterative pretests will be conducted to ensure that our process for reaching residents and encouraging their participation is appropriate and effective.

Tomas Philipson
"Economic efficiency and disparities in global health"

There have been many policy proposals for the problem of developing and distributing medicines for diseases mainly prevalent in poor nations. However, these proposals have not been explicitly analyzed from the perspective of economic efficiency and generally lack criteria by which the proposed remedies are optimal. We will address the issue of global health from an economic efficiency perspective, stating the problem as providing the correct R&D and distribution incentives under altruism. As we will argue, efficient provision of R&D incentives in the area of global health should reward innovators by the amount of altruism present in the tax-base of rich countries, and is not driven simply by consumer- and producer surplus. As part of this project, we will examine whether traditional economic R&D stimuli, including patents or prizes, encourage or fail to stimulate efficient R&D under altruism. We will also characterize existing popular policy proposals in the area of global health and evaluate their merits from the standpoint of economic efficiency. Finally, as part of our theoretical work, we will propose alternative methods of promoting global health that do not compromise economic efficiency.

As the major part of this project, we will collect and analyze data on the share of health care spending from foreign aid in poor countries. Under the assumption that foreign aid spending reflects society’s willingness to subsidize the positive externality generated by the provision of global public health, we will develop a model that allows us to quantitatively determine the amount of worldwide altruism towards the poor and underserved in the developing world.