Health Impacts of City-Wide Zero-Fare Bus Transit: A Natural Experiment

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PROJECT ABSTRACT Wide-reaching efforts are needed to increase population levels of physical activity and healthy eating in low- income groups for obesity- and type 2 diabetes prevention/control. Low-income groups experience higher rates of obesity and diabetes than the general population and the COVID-19 pandemic has made these groups even more vulnerable to developing these preventable chronic diseases. Active transportation is an underused source of physical activity but is particularly relevant to low-income groups. A major and consistent correlate of active transportation is use of public transit, and transit users engage in 5-15 more minutes/day of overall PA that non-users. Public transit may also support access to healthy eating and health services. Citywide policies to increase use of public transit have promise for improving health markers but have been substantially underexplored. As an effort to improve economic conditions among low-income groups, Kansas City, MO (KCMO; 500K residents; 43,000 daily bus trips) has become the only major city in the U.S. to permanently adopt an ongoing zero-fare bus transit (ZBT) policy. The policy has eliminated all bus fares across the city. This provides an extraordinary opportunity to examine impacts of such policies on bus ridership and subsequently on bus users' physical activity, healthy eating, and weight status. In this proposed study, we will collect bus ridership data before and up to 3 years after ZBT in KCMO and multiple comparison cities. To investigate health information, study participants will be recruited from a large primary care health system serving low- income communities. Participants will complete measures of bus use, and height and weight information will be obtained from the health system's electronic health record before and up to 3 years after ZBT. A subsample of participants will complete a 7-day objective physical activity assessment and questionnaires on their healthy eating, perceptions of the ZBT policy, and barriers/facilitators to riding the bus. Community residents will collect neighborhood environment information around bus stops to test as barriers to bus ridership and support advocacy efforts. A state-of-the-art synthetic control approach will be used to compare ridership trends across cities and weight status trajectories between post-ZBT bus users and non-bus users. The synthetic controls will be a weighted combination of multiple control participants to provide a better comparison than any single control alone. This study has significant implications for advancing knowledge and evidence on the potential health impacts of ZBT policies. Findings will produce information that will be usable by other natural experiment researchers and healthcare entities, as well as by local, state, and federal governments in making determinations on use of public policy approaches such as ZBT as a lever for obesity- and diabetes-related risk reduction in low-income communities.