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

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Project Summary. 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 fundamental cause of these racial health disparities is structural racism, which operates via interconnected, mutually reinforcing social and economic pathways. Notably, long-standing, 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,” which is strongly tied to poor health. To date, most interventions have focused on individual-level behaviors or single social determinants of health. However, by failing to address the multiple mechanisms that generate persistent health disadvantages for Black Americans, existing interventions have had limited impact. We propose to develop and test a radically different approach in which we intervene on multiple upstream drivers of health in unison to more substantially and durably improve health among Black Americans. This new approach is motivated by the insight that overcoming centuries of structural racism will require significant concentrated investment in the structures that have left Black people and their neighborhoods in peril. Specifically, we 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, we address underinvestment in Black neighborhoods by implementing vacant lot greening, abandoned house remediation, tree planting, and trash cleanup. At the organization level, we partner with community-based financial empowerment providers to develop cross-organizational infrastructure to increase reach and maximize efficiency. At the individual/household levels, we increase access to public benefits, financial counseling and tax preparation services, and emergency cash assistance. We will test this “big push” intervention in 60 Black neighborhoods, with a total of 720 adults. We hypothesize that this “big push” intervention will have significant impact on overall health and wellbeing, blood pressure, psychosocial distress, food insecurity, social connectedness, and violence. This proposal is innovative because when implemented simultaneously in targeted geographic areas, the suite of interventions will address the multiple mechanisms by which structural racism harms Black health. The positive health impacts will be multiplied and longer-lasting what would be achieved by implementing any individual component. The results of the proposed research are expected to have significant public health impact as it will provide timely and scalable evidence of new strategies to more effectively reduce racial disparities in health.