Building Wealth and Health Network: A Microfinance/TANF Demonstration Project

Study Overview
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Brief Summary
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The goals of the The Building Wealth and Health Network (The Network) are to develop and rigorously test an asset building model that will build financial, social and human capital through asset building, financial education and trauma-informed peer support. Program components include: 1) Matched savings accounts; 2) Financial literacy classes; and 3) Peer support groups using the Sanctuary ® trauma-informed approach to social services. This program is offered in partnership with the Department of Public Welfare of the Commonwealth of Pennsylvania. The program elements will fulfill work requirements for the program called temporary Assistance for Needy Families (TANF). The hypothesis is that the program's combination of services will result in improved economic security through boosting income, increasing assets, and building a supportive social network, that then translates to better health outcomes.

Detailed Description
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Families with young children under age six participating in The Temporary Assistance for NeedyFamilies Program (TANF) that are deemed work mandatory are required to participate in work-related activities for at least 20 hours per week in order to receive TANF benefits. However, due to financial hardship, poor health, and exposure to violence and adversity, the success families achieve through TANF participation can be limited. In 2013, 45.3 million people lived in poverty in the United States, including over one in five children under the age of six, yet only 27% of eligible families received Temporary Assistance for Needy Families (TANF). While child poverty increases the risk of poor health and developmental delays, many public assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and housing subsidies, protect vulnerable children from the negative effects of poverty. However, it is unclear if TANF has demonstrated significant improvements in maternal and child wellbeing, in moving families out of poverty, or in fully preparing low-income families for success in the workforce. One of the goals of TANF is to provide job skills and education programs to support adults and their children as they enter the workforce. However, many families experience barriers to employment, which may prevent them from successfully transitioning off of TANF. This may be due in part to poor health among those receiving TANF, as approximately one third of TANF recipients have reported a work-limiting health condition; and almost 43% of TANF recipients reported multiple types of disability including memory impairment, emotional/mental limitations, movement limitations, and sensory impairment. In addition to the poor health and disability reported by TANF participants, they also report alarmingly high rates of exposure to violence and adversity in their communities and in their family relationships. For instance, among TANF eligible families, rates of intimate partner violence are as high as 74% compared to up to 31% in the general community, posing a major barrier to rates of employment. While exposure to violence in adulthood indicates severe hardship, such exposure to violence across the lifespan, reaching back into childhood, is also reported at significantly higher rates among low-income families. Adverse childhood experiences (ACEs) consisting of physical and emotional abuse and neglect, sexual abuse, and household dysfunction, such as having a household member in prison, or witnessing domestic violence are especially prevalent among those receiving TANF. ACEs and violence exposure are closely linked to work-limiting conditions such as depression, cardiovascular disease, food insecurity and other health conditions. Exposure to ACEs has been linked to higher rates of worker absenteeism and stress surrounding work and finances in adulthood, indicating an association between ACEs and later financial stability. Other related barriers to work are having a criminal record, or having served time in prison, and among female heads of household TANF recipients, the prevalence of interactions with the criminal justice system is quite high compared to other low income populations. Finally, when a parent of a young child is in prison, it can have detrimental effects on the child's development, which in turn, demands more attention, time and care by adult caregivers, creating more barriers to work. Female heads of households who have a criminal history are at greater risk for reaching the TANF time limit which can exacerbate the barriers of obtaining employment. Furthermore, children whose parents have a criminal history are at a greater risk of becoming involved in the criminal justice system and are more likely to exhibit high-risk behaviors than children in the general population. The high levels of adversity among TANF recipients and those living in poverty is a significant concern because adversity impacts physical and mental health, academic achievement, employment, the development of executive skills such as working memory and cognitive controls, and parenting of the next generation. Emphasis on job search and work participation for families without attention to adversity and poor health can be a set up for failure. Preliminary evidence demonstrates that social support and comprehensive approaches to social work that build resilience may have strong success in limiting the negative impacts of exposure to violence and adversity. However, the majority of TANF programs across the country rarely integrate such approaches, and in many states, TANF participants that are unable to meet the mandated work requirements, potentially due to poor health and exposure to violence and adversity, may be more likely to be sanctioned, either have their cash benefits reduced, or cut off completely for a duration of time. Families that receive sanctions are more likely to have significant health barriers to work participation. Additionally, those that have been sanctioned reported higher rates of intimate partner violence, and physical and behavioral health problems. Sanctions can then increase hardships families already face. For instance, compared to families who have not been sanctioned, families that experience sanction report higher rates of household food insecurity, utility shut-offs, child hospitalizations, difficulty paying for health care, homelessness, and disruptions in children's schooling. This is especially problematic as those who are sanctioned often have young children, putting those children at increased risk during sensitive developmental phases. To compound the mental and physical barriers to work and self-sufficiency, TANF-eligible families, like many low income families, have low financial literacy, poor no credit history, few or no assets, and are unbanked (having no checking or savings account) or under-banked (having a bank account, but still primarily relying on alternative financial services such as check cashing and money orders). In order to supplement meager income, families may resort to earning income and spending money through the informal economy where they are paying higher fees for check cashing, paying bills, and acquiring loans. This lack of access to mainstream financial institutions and activities can be crippling, as savings and other tangible assets play a critical role in helping shield families from unexpected income shocks, allowing families to weather periods of economic uncertainty without falling further into poverty. Savings create a financial foundation, increase economic security, and can be, over time, invested into education for children. Asset building activities show improvements in health, greater civic and community involvement, and lower rates in the intergenerational transfer of poverty. Savings can also reduce the extreme stress that often accompanies maternal depression. Finally, the positive impacts of savings have held true even during the recession. In partnership with the state of Pennsylvania Health and Human Services Department, The Building Wealth and Health Network (The Network), a randomized, controlled pilot study, sought to evaluate effectiveness of an intervention to address family hardships associated with exposure to adversity and violence, social isolation, and low financial capability in order to help families get on the pathway to self-sufficiency.

Official Title
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Building Wealth and Health Network: A Microfinance/TANF Demonstration Project

Conditions
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Hunger, Child Development, Social Isolation

Intervention / Treatment
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* Behavioral: Self Empowerment Groups
* Behavioral: Financial Empowerment
* Behavioral: Matched Savings


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Recipients of TANF cash benefits for four years or less, and Subject to mandatory TANF 20-hour work requirement, and Parents of at least one child below the age of six Exclusion Criteria: Adults who are unable to provide consent

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Self Empowerment Groups<br>Intervention activities included helping participants to open savings accounts at a local federal credit union with 1:1 matches of up to twenty dollars per month for 12 months. Participants also received financial empowerment and Peer Support curriculum, weekly for about 3 hours per week for 28 weeks. | Behavioral: Self Empowerment Groups<br>* The Self Empowerment Groups (SEG) curriculum draws key components from the S.E.L.F. tool within Sanctuary, focusing the four domains: creating personal, emotional, moral and physical safety (S), processing and managing emotions (E), recognizing loss and letting go (L), and developing goals for a sense of future (F). S.E.L.F. establishes a common language that all people who have experienced adversity can use to organize their lives and work towards building stable foundations to support their goals and invest in their potential.<br>Behavioral: Financial Empowerment<br>* The Financial Empowerment curriculum developed for this study consisted of interactive exercises, worksheets, and journal assignments that fostered understanding and practice of banking, building credit and debt management, making the most of one's money, and setting financial goals for oneself and one's family. Content focused on identifying and harnessing the internal and external resources that participants can leverage to begin taking steps towards financial self-sufficiency.<br>Behavioral: Matched Savings<br>* Participants were assisted with opening a savings accounts at a local non-profit federal credit union (with 1:1 matches of up to twenty dollars per month) over the course of 12 months.<br>|
| Experimental: Financial Empowerment<br>Intervention activities included helping participants to open savings accounts at a local federal credit union with 1:1 matches of up to twenty dollars per month for 12 months. Participants also received financial empowerment weekly for about 3 hours per week for 28 weeks. | Behavioral: Financial Empowerment<br>* The Financial Empowerment curriculum developed for this study consisted of interactive exercises, worksheets, and journal assignments that fostered understanding and practice of banking, building credit and debt management, making the most of one's money, and setting financial goals for oneself and one's family. Content focused on identifying and harnessing the internal and external resources that participants can leverage to begin taking steps towards financial self-sufficiency.<br>Behavioral: Matched Savings<br>* Participants were assisted with opening a savings accounts at a local non-profit federal credit union (with 1:1 matches of up to twenty dollars per month) over the course of 12 months.<br>|
| No Intervention: Control Group<br>The Control group did not receive assistance in opening a matched savings account, and were required by the County Assistance Office to participate in other Temporary Assistance for Needy Families (TANF) mandated work participation activities according to standard procedure. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in family economic hardship | Family economic hardship is a singular outcome captured in three measures of hardship: 1) The U.S Household Food Security Survey Module (HFSSM) which measures food insecurity, 2) an energy security survey, which measures energy insecurity, and 3) a housing security survey, which measures housing instability. These three measures combine into a singular measure of hardship that consists of No hardship [no positive response to three hardships above] Moderate hardship [at least one of the three hardships] and Severe hardship [consisting of 2 or 3 hardships] | Quarterly change for up to 15 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Career readiness | Career readiness is measured using the employment hope scale. | Quarterly change for up to 15 months | 
| Change in Mental Health | To assess depressive symptoms among adult participants, we used the Center for Epidemiologic Studies Depression (CES-D). | Quarterly change for up to 15 months | 
| Change in Child development | Children's developmental status was measured by the Parents' Evaluations of Developmental Status Survey. Participants were asked ten questions about their child's developmental issues: global/cognitive, expressive language and articulation, fine-motor, gross motor, behavior, social-emotional, self-help, school, and any other concerns. | Quarterly change for up to 15 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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food insecurity, adverse childhood experiences, violence exposure, trauma, poverty, TANF, assets, depression, randomized control trial