Springfield, Massachusetts is a mid-sized city with a large community of color population experiencing socioeconomic and health inequities. Historically there has been little infrastructure in Springfield to support active transportation and recreational walking and biking, so in 2015, Springfield City Council adopted a city-wide “Complete Streets” resolution.

“Complete Streets” policies enable safe access for pedestrians, bicyclists, transit users, and motorists of all ages and abilities, yet little empirical evidence has documented their impact on the community and health and well-being.

This study will investigate, through an equity lens, whether Complete Streets policies lead to changes in:

• The built environment (e.g. traffic calming; bicycle/pedestrian facilities),
• The economic environment (e.g. retail activity),
• The social environment (e.g. perceived safety, social cohesion), and
• Health/health behaviors (e.g. physical activity).

The study will use existing and original data, including objectively measured physical activity. Research will be conducted in partnership with community partners to leverage collective expertise and existing data collection efforts, to engage residents as research partners, and ensure results and research products are designed and disseminated to benefit the community and foster health equity. Resident perception of the policy and infrastructure changes will also be assessed.

Complete Streets policies have the potential to impact equity by creating activity-friendly environments in communities experiencing large social, economic, and health inequities. This study seeks to determine if the policies can and do achieve that potential.

There is an urgent need to understand long-term health, developmental, and educational outcomes for children who experience early life stressors. In Tennessee alone, over 22% of all children live in poverty. The number of children born between 2001 and 2014 with neonatal abstinence syndrome (NAS) increased 25-fold, and children of immigrants, 36% of whom live in poverty in Tennessee, often struggle to access the social services they need to thrive.

To fill this gap, the multidisciplinary research team will work alongside key state partners to develop an actionable research portfolio that clarifies the long-term effects of these early life experiences and illuminates the ways state policies can be adapted or modified to better serve the needs of Tennessee families.

Leveraging more than a decade’s worth of data, the researchers will examine relationships between at-risk children’s health and education outcomes, as well as access to public services. This is vital information as states across the country, and Tennessee in particular, adopt new laws and resolutions that encompass a wide range of policy actions related to child health and education.

Although the research portfolio will evolve with input from partners including state agencies and non-profits focused on child outcomes, the team will focus their initial efforts around several key issues:

The Opioid Epidemic

Tennessee is one of the states most affected by the opioid epidemic, particularly among its children. Opioid-related policies operate amid a backdrop of public programs like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and The Early Intervention Program for Infants and Toddlers with Disabilities (IDEA Part C), which seek to mitigate health and educational disparities between opioid-exposed children and non-opioid-exposed children.

The research team will begin by examining longitudinal health outcomes for opioid-exposed children, assessing how likely they are to have developmental delays, special health care needs, and adequate utilization of preventive services. The team will also examine whether county-level trends in the proportion of children with attendance and discipline problems and low test scores correlate with periods of time when neonatal abstinence syndrome (NAS) reached epidemic proportions in their counties. They will then use linked TennCare Medicaid and educational data to undertake individual-level analyses of differences in educational outcomes (e.g., attendance, discipline, and test scores) between children born with NAS and children not born with NAS.

Access to Public Services

Past research has shown that children living in poverty are less likely to complete secondary and tertiary education and more likely to lack health insurance. Children of immigrants who are eligible for public programs and benefits may also need additional support in accessing those benefits, which in turn could aid families in creating a healthier and more nurturing home environment for their development.

Since 2009, Tennessee has introduced more than 20 legislative actions addressing eligibility verification for public program participation. To better understand the impact of these policies, the research team will examine associations between these policy changes and children’s access to Medicaid coverage and other social services in Tennessee, particularly for special needs children.

In addition, the team will investigate ways to improve children’s access to essential health, education, and other social services in Tennessee by conducting key informant interviews with state and local agencies that administer programs, along with school district personnel and nonprofit organizations that assist families in accessing program benefits for children.

Amid a growing national conversation on equity and social justice, city and county governments are using tools to identify racial and ethnic disparities in their communities. These insights can then inform the development and implementation of laws and policies designed to minimize disparities and maximize positive impacts on racial and ethnic minorities. Nearly 200 city and county governments have adopted tools developed by GARE/Race Forward, Living Cities, PolicyLink and PERE, but no one has yet catalogued whether the adoption of these tools has resulted in changes to laws and policies related to employment, housing, access to health care, and childhood education—key social determinants of health.

Working closely with the tool developers, the research team will identify characteristics of cities and counties that have adopted racial equity tools, as well as their stages of readiness for law and policy change. The team will assess the type(s) of equity tool(s) being used, tool source, duration of tool use, community engagement, focus of law and policy changes, and advocacy strategies for law and policy change. In the second phase of the project, the team will conduct four in-depth case studies on a selected city or county’s stage of readiness to change, adoption process of racial equity tools, and influence of racial equity tool adoption on law and policy changes.

The data collected will be used to 1) develop a comprehensive map and database that describes the city/county, the type(s) of racial equity tool(s) adopted, and the stages of readiness to engage in law and policy change; and 2) an adoption map to delineate where governmental adoption of racial equity tools influenced developments and modifications in laws and policies related to at least one SDOH.

Building on our Health of the States Project, we will examine the impact of state social spending and health policies on health and developmental outcomes among children. We are proposing a focus on children because health and developmental trajectories begin in childhood; we can capture spending policies over the course of their lifetime; and the vast majority of children live in the same state that they were born for their entire childhood (US Census 2011).

We will use data from three waves of the National Survey of Children’s Health (NSCH) matched by birth cohort, county, and state to historical data from the Census of Governments, which tabulates state and local government spending by category of service. We will examine four types of state spending: education, income support, housing and community development, and libraries, parks and recreation. To control for state spending on health we will include public health spending from the Census of Governments and also Medicaid eligibility thresholds for children and parents. These data will allow us to develop measures of exposure to several types of government social spending during three key developmental phases of childhood.