“Our takeaway is really about the importance of investing in communities in a way that makes people feel cared for—in terms of what their environment looks and feels like—and gives them agency and autonomy to spend on what feels most important.”
Atheen Venkataramani and Aditi Vasan are part of the research team on Philadelphia’s IGNITE study, which combines financial interventions (a one-time cash grant, financial counseling and support with benefits enrollment) and environmental interventions (tree planting and trash pickup) in neighborhoods and looks at how both “treatments” affect health, including self-reported health outcomes, hospitalizations and crime.
Atheen is a health economist at the University of Pennsylvania and the director of the Opportunity for Health Lab, and his work has focused on the social and economic forces that shape health and inequality. Aditi is a pediatrician at Children’s Hospital of Philadelphia (CHOP) and health policy researcher at the University of Pennsylvania who focuses on improving the health and social service systems serving children and families living in poverty, including through reducing barriers to benefits like WIC, SNAP and Medicaid.
Here, Atheen and Aditi discuss how health is profoundly affected by the environments we live in, the IGNITE and IGNITE Kids research studies and what they’ve learned so far.
Q: You both have focused your research on how place and policy influence health and well-being. What do we know about the impact of our environments and social policies on health?
Atheen: Our prevailing narrative in the U.S. has been that “your health is in your hands.” Meaning that individuals determine their own health. The problem with that framing is that so much of what drives our physical and mental health has to do with structural factors. We live in communities and are affected by forces bigger than us.
Safety net policies influence what we’re able to access, environmental policies affect whether we have clean air and water, and labor markets and policies affect unemployment or job supports. There are places that have been chronically disinvested in where it’s hard, at a neighborhood level, to acquire wealth and health.
Policy choices also affect the way people think about their future: “Am I in a world where I feel like I belong? One where I can expect to have a bright future and actualize that?”
All of these factors influence how easy or difficult it is for people to manage stress and be healthy.
Aditi: My broad interest is in economic opportunity and economic justice. I think about that both at the family level, when people come to see us in the hospital, and at the systems level, in how we can design all the systems that kids and families interact with to be more equitable and accessible. I want my work to extend to the environments that kids go home to, the resources they have access to and the systems they interact with.
I’m limited in what I can do inside the hospital. Part of the goal of my research is to uplift economic support policies like tax credits, or programs like WIC, SNAP and Medicaid, as important levers to improve child health and well-being. The more you can do at a population level, the larger the health impact you’re likely to see.
Q: What was the gap you were trying to address with IGNITE, and how was the intervention structured?
Atheen: About five years ago, the NIH was funding studies with ‘high risk, high reward’ interventions that could potentially move the needle. We proposed a multi-component, household and place-based intervention in West and North Philadelphia, where there’s been entrenched disadvantage for racial minority groups for many, many generations.
Aditi: Often, interventions to address structural racism and economic disinvestment focus on a single intervention, while these problems are so complex and multifaceted. Intervening not just on one determinant of health, but on a suite of environmental and economic inequities, can produce learnings to inform policies and population- level interventions.
Atheen: In the IGNITE study, about 600 people were enrolled in total and we randomized half of them to receive the ‘treatment’ and the other half didn’t.
At the household level, folks got a one-time $400 cash transfer as an incentive to see a free financial counseling service, which about 75% of people took up. We also worked with community partners to provide support with applying for benefit programs, like Medicaid and SNAP, and free tax preparation. At the environmental level, our partners at the Philadelphia Horticultural Society did vacant lot remediation, trash cleanup and tree planting.
We hired four community coordinators who enrolled participants and made warm handoffs to our community partners for the income supports. We have 58 block areas, which are 4 blocks by 4 blocks, and we enrolled eight to 12 people per cluster.
Our main outcome is people’s health. We are using self-reported health data, which has been shown to correlate well with people’s actual health and mortality risk. We are also looking at crime, hospitalizations and child welfare involvement using administrative data, but are still in the early stages of looking at those outcomes.
Aditi: Once we got funding for the original study, we had an opportunity to run a second, smaller study called IGNITE Kids. We are recruiting additional families with children from each of the clusters to learn how child health may have changed as a result of the intervention.
Q: What have you learned so far about how neighborhood conditions are impacting family life?
Aditi: At baseline, we were trying to understand: How do your neighborhood conditions and economic conditions make you feel? We’re still in the stage of analyzing data but have some preliminary results.
We heard about how the neighborhoods where families live affect whether they feel like their kids are safe. People described environmental disinvestment. When their neighborhood wasn’t something that people were putting a lot of effort into, it made them feel less comfortable with their children playing outside. And parents didn’t always have the funds for their children to participate in safe recreational activities.
Families also talked about how financial strain impacted their child’s mental health. Parents and grandparents do a lot to try to shield kids from the effects of financial strain, but children know when parents are having a hard time paying the bills or when they themselves are going without food so that kids can eat.
Q: What has been the effect of the intervention so far?
Atheen: Over the course of the study, we’ve averted over 1,200 crimes in the clusters that received the interventions—most of them serious crimes. Just on that one outcome alone, we’ve saved the government money. The “social cost” of those crimes is more than what the study cost. And that doesn’t account for the fact that crime also fell in surrounding areas. If we counted those neighborhoods, the intervention averted over 2,000 crimes.
Aditi: We heard that the neighborhood level interventions helped people feel cared for and safe. People talked about how, when they brought their daughter outside, there was a green space where there used to be a vacant lot. Now, trash was picked up where it used to be sitting on the street.
Families shared that seeing their neighborhood change improved their child’s mental health. It changed their mood and affect—they suddenly wanted to run around and be outdoors. It changed the way that the child saw the neighborhood too. Seeing a different neighborhood than what you’re used to affects the way that you see yourself, your family and your community.
Atheen: Interestingly, we can’t pin the reductions in crime on greening or trash cleanup. It seems to happen as soon as we enter the cluster, before we do anything else. We might find that it was the four community coordinators who delivered the study that had the treatment effect. It’s possible that us being in the field sends signals that there’s active surveillance from a large institution, and that could have a deterrent effect on crime. We can’t know for sure, but it’s interesting to think that just by showing up, you might get really far in changing people’s expectations about the future.
I’m curious to see what happens with the health outcomes, which include self-reported measures as well as administrative measures on hospitalizations and emergency department visits. It’s tricky because there’s been more uncertainty around benefit programs and the economy over the last couple of months, when a lot of the data collection happened. That might reduce our ability to see a treatment effect.
Aditi: From a financial perspective, almost everyone in our initial interviews talked about investing the resources they got in ways that supported their family. Having even a little bit of that financial stress alleviated allowed them to put their time and energy into their kids and invest in their kids in different ways. We heard a lot of stories where physical- and mental health-promoting activities were really enabled, like being able to play on a sports team with your friends or buy a new dress for graduation.
There were families who didn’t know what benefit programs they were eligible for or had trouble navigating the application process. For tax preparation, we also heard from families who felt mistrust towards the government or predatory private agencies that were promising refunds. Having trusted community partners walk families through these programs made a big difference. Our participants felt like there was someone looking out for them, someone on their team.
Q: How might these findings inform policy?
Aditi: Our takeaway is really about the importance of investing in communities in a way that makes people feel cared for—in terms of what their environment looks and feels like—and gives them agency and autonomy to spend on what feels most important. People want to feel like the cities, states and places where they live—care enough to make their community livable, comfortable and safe.
A limitation of any randomized control trial is that we’re helping just eight or 12 families in each of these clusters. We’ve learned that the effects likely diffuse to many more families because a lot of people are altruistic and look out for their neighbors. The environmental benefits obviously have spillover effects, but it also points to the importance of population-level interventions. Our hope is that the evidence we generate will be used to inform policy changes that impact entire communities. Something like the child tax credit or a guaranteed income program that uplifts everyone in a community can certainly have a larger population health impact.
Atheen: There is not a single, ‘magic bullet’ type of intervention that can lift up marginalized communities and help them thrive. It requires real investment in complementary pieces of people’s lives.
I think we’re too enamored with testing one thing at a time. The more we can understand how different components of people’s lives work together, that’s going to be a much more productive way forward.
A lot of research in my lab finds that policy effects on health go beyond changing access to material resources. What seems to have big impacts on health are the social policies that change people’s beliefs about themselves, where they’re headed and what they can do in life.
Interview by Mahima Golani