The IGNITE Study on Concentrated Investment in Black Neighborhoods

A Randomized Controlled Trial of Concentrated Investment in Black Neighborhoods to Address Structural Racism as a Fundamental Cause of Poor Health

Black Americans in the US fare worse across nearly every health indicator compared to White individuals. In Philadelphia, the location of this study, these health disparities culminate in a stark longevity gap, with average life expectancies in poor, predominantly Black neighborhoods being 20 years lower than in nearby affluent, predominantly White neighborhoods. The investigators will conduct a cluster randomized controlled trial (RCT) of a suite of place-based and financial-wellbeing interventions at the community, organization, and individual/household levels that address the social determinants of racial health disparities. At the community level, the investigators address underinvestment in Black neighborhoods by implementing vacant lot greening, abandoned house remediation, tree planting, and trash cleanup. At the organization level, the investigators partner with community-based financial empowerment providers to develop cross-organizational infrastructure to increase reach and maximize efficiency. At the individual/household levels, the investigators increase access to public benefits, financial counseling and tax preparation services, and emergency cash assistance. The investigators will test this "big push" intervention in 60 Black neighborhood microclusters, with a total of 720 adults. The investigators hypothesize that this "big push" intervention will have significant impact on overall health and wellbeing.

Black individuals in the United States fare worse than White individuals across almost every social, economic, and health indicator. The Black health disadvantage starts at birth, reflecting the cumulative toll of racialized social stressors and healthcare discrimination on maternal health and resulting in higher rates of preterm birth and low birth weight. Black youth are disproportionately exposed to environmental toxins such as lead and adverse childhood events such as financial hardship and neighborhood violence. Black adults have higher rates of chronic disease, including diabetes, hypertension, as well as many cancers. These and other forces culminate in a stark racial longevity gap: in Philadelphia, the location of this study, life expectancy for people living in a poor, predominantly Black neighborhood is 20 years lower than for people living in a nearby affluent, predominantly White neighborhood. The fundamental cause of these striking and pervasive disparities is structural racism - the confluence of deep historical, institutional, cultural, and ideological forces that unequally distribute resources and risks across racialized groups. Structural racism patterns health by affecting a range of interconnected, mutually reinforcing social determinants of health at the national, neighborhood, household, and individual levels. Most notably, longstanding, systematic disinvestment has resulted in highly segregated Black neighborhoods with dilapidated environmental conditions and severe economic insecurity within Black households, leading to a "feedback loop of concentrated racial disadvantage," all of which have been strongly tied to poor health. Most interventions seeking to address racial health disparities focus on individual-level behaviors and outcomes, or individual channels by which structural racism harms health. However, by failing to address upstream social determinants, these interventions have had limited population level impact. A multi-level, multi-component intervention package focused on a range of social determinants of health is necessary to meaningfully address structural racism as a fundamental cause of racial health disparities.

Financial Stress, Economic Problems, Environmental Exposure, Health Behavior, Health, Subjective, Mental Health Wellness 1

The investigators are not masked. Our recruitment team will be masked until cluster recruitment is complete. The outcomes assessor will be masked.

At the individual level, participants in the intervention arm receive place-based and financial well-being interventions. These include, at the individual level: Tax preparation Access to public benefits Financial counseling and microgrants At the neighborhood level: Abandoned house remediation Trash cleanup Vacant lot greening Tree planting

Composite index using method of Anderson (2008) based on three questions: rating of overall health (5-pt Likert ranging from poor to excellent); rating of how health has changed in last 6 months (better, same, worse); and number of days in the last 30 where physical or mental health precluded engagement in usual activities (self-care, work, recreation); (Oregon Health Insurance Experiment)

Kessler-6 (answers scored 0-24 with higher scores indicating higher levels of psychological distress)

Rating of overall health (5-pt Likert ranging from poor to excellent) (Oregon Health Insurance Experiment)

Whether individual reported either poor or fair health to overall health question (Oregon Health Insurance Experiment)

Number of days in the last 30 where physical or mental health precluded engagement in usual activities (self-care, work, recreation)

Whether or not individual (or someone in household on behalf of individual) filed previous years income tax (yes, planning to file late, no) (internally developed)

Participation of a household member (including respondent) in Medicaid, Medicare, Medicare savings, LIS, CHIP, Qualified Health Plans, SelectPlan, other, or none (internally developed)

Participation of a household member (including respondent) in SNAP, WIC, Senior Food Box, other, or none (internally developed)

Participation of a household member (including respondent) in TANF, LIHEAP, SSI/SSDI, UI, PA General Assistance, PA Emergency Rental Assistance, EITC, CTC Refugee Cash Assistance, CCIS, PA Child Care Tax Credit, other, or none (internally developed)

Participation of a household member (including respondent) in PTRR, Homestead Exemption, LOOP, Basic Systems Repair Program, PA Homeowner Assistance, Philly First Home Program, Philadelphia Home Repair Assistance, other or none (internally developed)

Frequency with which individual visits a greenspace (such as a park, garden, greened vacant lot, trail, or any other outdoor space with vegetation) (adapted from Evenson et al 2013 Environment and Behavior)

Time spent in a greenspace on a typical day (adapted from Evenson et al 2013 Environment and Behavior))

Things that stop an individual from spending time in greenspace (adapted from Evenson et al 2013 Environment and Behavior)

Whether or not individual has concerns about planting more trees in neighborhood (internally developed)

Whether or not individual believes trees confer health benefits (e.g., safety, mental health benefits, physical health benefits, social benefits, environmental benefits, aesthetic benefits)

Frequency with which individual endorses spending time relaxing, socializing, or hanging out in porches, stoops, and front yards of neighborhoods (adapted from Kahneman et al 2004 Science)

Neighborhood Social Cohesion & Exchange and Social & Physical Disorder Scale (two domains: Social Cohesion and Physical Disorder. Higher scores for social cohesion indicate higher levels of social cohesion and higher scores for physical disorder indicate higher levels of physical disorder).

Whether or not participant reports a lot of abandoned buildings in their neighborhood (Ross and Mirowksi)

Quarterly data from 24 months (8 quarters) prior to enrollment and 12 months (4 quarters) after intervention period complete

Quarterly data from 24 months (8 quarters) prior to enrollment and 12 months (4 quarters) after intervention period complete

Inclusion Criteria: At least 18 years of age Have the ability to communicate via text messaging Individuals comfortable communicating in English A permanent resident of the home where they are to be enrolled Have knowledge of their household finances Exclusion Criteria: Individuals who plan to move out of the study microcluster within 6 months Individuals who are unable to fully consent and participate based on recruitment team assessment