Cost analysis and cost effectiveness of a subsidized community supported agriculture intervention for low-income families.

BACKGROUND: The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts. METHODS: Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016-2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers' daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives. RESULTS: F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver's FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity. CONCLUSIONS: Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www. CLINICALTRIALS: gov/ct2/show/NCT02770196 .

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education.

OBJECTIVE: Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention. DESIGN: Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later. PARTICIPANTS: Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148). INTERVENTION: Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis. VARIABLES MEASURED: Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner. ANALYSIS: Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence. RESULTS: At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107). CONCLUSIONS AND IMPLICATIONS: Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

Multi-stakeholder perspectives on the implementation of a clinic-based food referral program for patients with chronic conditions: a qualitative examination.

Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.

Food insecurity can make the self-management of diet-related chronic conditions (e.g., diabetes, hypertension, and obesity) difficult. Clinic-based food referral programs (FRPs) can help address the diet-related needs of food-insecure primary care patients by improving access to nutritious foods. However, the factors contributing to successful FRP implementation in primary care settings are underexplored. The focus of this study was to explore the barriers to and facilitators of implementation of an FRP offered to food-insecure primary care patients with chronic conditions seen at an academic medical center using a multi-stakeholder approach. Competing clinical and patient demands, patient transportation barriers, and food pantry-related stigma were salient factors that prevented healthcare providers and patients from engaging fully with the FRP. Inadequate provider feedback about patients' use of the FRP was also cited as a deterrent to greater provider engagement with the FRP. Critical facilitators of implementation included support and encouragement from program champions and having a coordinated referral process. The intentional branding and presentation of the FRP to eligible patients may have helped encourage its use by destigmatizing the food pantry setting. The impact of optimizing FRP implementation on patient use and program effectiveness warrants further research.

Utilization Patterns of a Food Referral Program: Findings from the Mid-Ohio Farmacy.

INTRODUCTION: There is limited evidence describing utilization of clinic-based food referral programs intended to support healthy eating for food-insecure patients. To address this gap, this study aims to describe the utilization of the Mid-Ohio Farmacy (MOF). MOF is a partnership between a regional foodbank and local health care providers, including an academic medical center (AMC), that enables referrals of patients that experience food insecurity to a network of participating food pantries. METHODS: This observational study uses data from 2 AMC family medicine clinics that offered the MOF referral from September 2019 to November 2020. Patients who screened positive for food insecurity and had an eligible chronic disease (eg, diabetes, hypertension, obesity) were referred to the MOF. We compared demographic and clinical characteristics of patients that filled their referral (ie, visitors) to those that did not (ie, non-visitors). Among visitors, we also assessed patterns of pantry utilization. RESULTS: In total, 51% (164 of 322) of patients referred to the MOF visited a food pantry at least once. Visitors were more likely to be older, have diabetes, and have visited a food pantry before their referral. Patients with uncontrolled hypertension were less likely to visit a food pantry following their referral. Patients that had visited a food pantry before their referral had more visits in total and more produce-specific visits following their referral. CONCLUSIONS: Our results suggest that while the MOF can connect patients to food resources, further attention may be needed to encourage its use among patients who have not previously accessed pantries.

Local Value Chain Models of Healthy Food Access: A Qualitative Study of Two Approaches.

Food value chains are increasingly recognized as more equitable alternatives to traditional supply chains and may represent a novel mechanism to achieve health equity at the local level. Country Fresh Stops (CFS) and Donation Station (DS) are two complementary programs that are part of a more robust value chain designed to support local agriculture in Appalachia Ohio. As the first study of these programs in the peer-reviewed literature, the objectives were to identify factors that facilitate or hinder the implementation of these two local value chain models of healthy food access and to identify the perceived impacts from the perspective of the sites implementing them. In-depth, semi-structured interviews were conducted with CFS (n = 7) and DS (n = 10) site representatives in January 2020. Template analysis was used to identify themes through a priori and inductive codes. Participants identified two primary facilitators: support from partner organizations and on-site program stewardship. Produce (and program) seasonality and mitigating food waste were the most cited challenges. Despite challenges, both CFS and DS sites perceive the models to be successful efforts for supporting the local economy, achieving organizational missions, and providing consumers with greater access to locally grown produce. These innovative programs demonstrate good feasibility, but long-term sustainability and impacts on other key stakeholders merit further investigation.

Making community-supported agriculture accessible to low-income families: findings from the Farm Fresh Foods for Healthy Kids process evaluation.

A randomized trial of Farm Fresh Foods for Healthy Kids (F3HK) was initiated across 4 states and 12 farms to test whether cost-offset community-supported agriculture (CO-CSA) could improve diet quality among children in low-income families. Intervention households purchased a 50% subsidized share of local produce and were invited to nine complimentary nutrition classes. The purpose of this study was to assess F3HK reach, dose, and fidelity via a mixed methods process evaluation. Screening and enrollment records indicated reach; study records and postlesson educator surveys tracked dose delivered; CSA pickup logs, lesson sign-in sheets, postseason participant surveys, and postlesson caregiver surveys assessed dose received; and coordinator audits and educator surveys tracked fidelity. Educator interviews contextualized findings. The results of this study were as follows. Reach: enrolled caregivers (n = 305) were older (p = .005) than eligible nonenrollees (n = 243) and more likely to be female (p < .001). Dose: mean CSA season was 21 weeks (interquartile range [IQR]: 19-23). Median CSA pickup was 88% of the weeks (IQR: 40-100). All sites offered each class at least once. Most adults (77%) and children (54%) attended at least one class; few attended all. Eighty-two percent of caregivers indicated that their household consumed most or all produce. Median lesson activity ratings were 5/5 ("very useful"). Fidelity: CSA locations functioned with integrity to project standards. Educators taught 92% of activities but frequently modified lesson order. This study demonstrates the feasibility of pairing a CO-CSA intervention with nutrition education across geographically dispersed sites. Greater integration of intervention elements and clearer allowance for site-level modifications, particularly for educational elements, may improve intervention dose and, ultimately, impact.

A Qualitative Evaluation of Double Up Food Bucks Farmers' Market Incentive Program Access.

OBJECTIVE: Explore factors affecting access to and use of Double Up Food Bucks (DUFB), a farmers' market program that doubles Supplemental Nutrition Assistance Program benefits for use toward the purchase of fruits and vegetables (FV). DESIGN: Focus groups. SETTING: Metro and nonmetro counties in Utah and western Upstate New York. PARTICIPANTS: Nine groups composed of 62 low-income adults (3-9/group). PHENOMENA OF INTEREST: Satisfaction with, barriers to, and facilitators of program use; suggestions for improvement. ANALYSIS: Transcribed verbatim and coded thematically in NVivo 11 software according to template analysis. RESULTS: Program satisfaction was high and driven by FV affordability, perceived support of local farmers, positive market experiences, and high-quality FV. Primary barriers to using DUFB were lack of program information and inconvenient accessibility. Insufficient program communication was a consistent problem that elicited numerous suggestions regarding expansion of program marketing. Emergent topics included issues related to the token-based administration of DUFB and debate regarding stigma experienced during DUFB participation. CONCLUSIONS AND IMPLICATIONS: Results suggest that although DUFB elicits many points of satisfaction among users, program reach may be limited owing to insufficient program marketing. Even among satisfied users, discussion of barriers was extensive, indicating that program reach and impact may be bolstered by efforts to improve program accessibility.

Farm Fresh Foods for Healthy Kids (F3HK): An innovative community supported agriculture intervention to prevent childhood obesity in low-income families and strengthen local agricultural economies.

BACKGROUND: Childhood obesity persists in the United States and is associated with serious health problems. Higher rates of obesity among children from disadvantaged households may be, in part, attributable to disparities in access to healthy foods such as fruits and vegetables. Community supported agriculture can improve access to and consumption of fresh produce, but the upfront payment structure, logistical barriers, and unfamiliarity with produce items may inhibit participation by low-income families. The aim of this project is to assess the impact of subsidized, or "cost-offset," community supported agriculture participation coupled with tailored nutrition education for low-income families with children. METHODS/DESIGN: The Farm Fresh Foods for Healthy Kids community-based, randomized intervention trial will build on formative and longitudinal research to examine the impact of cost-offset community supported agriculture on diet and other health behaviors as well as the economic impacts on local economies. The intervention will involve reduced-price community supported agriculture shares which can be paid for on a weekly basis, nine skill-based and seasonally-tailored healthy eating classes, and the provision of basic kitchen tools. Low income families with at least one child aged 2-12 years will be recruited to join existing community supported agriculture programs in New York, North Carolina, Vermont, and Washington. In each program, families will be randomized 1:1 to intervention or delayed intervention groups. Data will be collected at baseline, and in the fall and spring for 3 years. The primary outcomes are children's intake of fruits and vegetables and foods high in sugar and/or (solid) fat, as well as diet quality; secondary outcomes include physical, behavioral, psychosocial, and environmental variables. Cost-effectiveness and economic impact at the farm and community levels also will be assessed. DISCUSSION: This integrated project will provide important information and contribute to the evidence base regarding the use of local agricultural interventions to improve children's dietary behaviors and weight maintenance. Findings also will inform the development of a toolkit for farmers and education modules related to local food system innovations for undergraduate and graduate students. TRIAL REGISTRATION: ClinicalTrials.gov NCT02770196 . Registered 5 April 2016.

Rural Food and Physical Activity Assessment Using an Electronic Tablet-Based Application, New York, 2013-2014.

INTRODUCTION: A community's built environment can influence health behaviors. Rural populations experience significant health disparities, yet built environment studies in these settings are limited. We used an electronic tablet-based community assessment tool to conduct built environment audits in rural settings. The primary objective of this qualitative study was to evaluate the usefulness of the tool in identifying barriers and facilitators to healthy eating and active living. The second objective was to understand resident perspectives on community features and opportunities for improvement. METHODS: Participants were recruited from 4 rural communities in New York State. Using the tool, participants completed 2 audits, which consisted of taking pictures and recording audio narratives about community features perceived as assets or barriers to healthy eating and active living. Follow-up focus groups explored the audit experience, data captured, and opportunities for change. RESULTS: Twenty-four adults (mean age, 69.4 y (standard deviation, 13.2 y), 6 per community, participated in the study. The most frequently captured features related to active living were related to roads, sidewalks, and walkable destinations. Restaurants, nontraditional food stores, and supermarkets were identified in the food environment in relation to the cost, quality, and selection of healthy foods available. In general, participants found the assessment tool to be simple and enjoyable to use. CONCLUSION: An electronic tablet-based tool can be used to assess rural food and physical activity environments and may be useful in identifying and prioritizing resident-led change initiatives. This resident-led assessment approach may also be helpful for informing and evaluating rural community-based interventions.