How the Gus Schumacher Produce Prescription Program Works: An Adaptation of a Nutrition Incentive Theory of Change.

The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports nutrition incentive (NI) and produce prescription programs (PPRs). PPRs allow healthcare providers to "prescribe" fruits and vegetables (FVs) to patients experiencing low income and/or chronic disease(s) and who screen positive for food insecurity. We developed a Theory of Change (TOC) that summarizes how and why PPRs work, identifies what the programs hope to achieve, and elucidates the causal pathways necessary to achieve their goals. We created the PPR TOC through an iterative, participatory process that adapted our previously developed GusNIP NI TOC. The participatory process involved food and nutrition security experts, healthcare providers, PPR implementors, and PPR evaluators reviewing the existing NI TOC and suggesting modifications to accurately reflect PPRs. The resulting TOC describes the mechanisms, assumptions, rationale, and underpinnings that lead to successful and equitable outcomes. Modifications of the NI TOC centered around equity and focused on inclusion of healthcare as an additional partner and the importance of health and healthcare utilization as outcomes. The TOC describes how the GusNIP PPR program reaches its goals. This understanding will be useful for PPR developers, implementers, funders, and evaluators for describing the pathways, assumptions, and foundations of successful PPRs.

A Case for Using Electronic Health Record Data in the Evaluation of Produce Prescription Programs.

Produce prescription programs within clinical care settings can address food insecurity by offering financial incentives through "prescriptions" for fruits and vegetables to eligible patients. The electronic health record (EHR) holds potential as a strategy to examine the relationship between these projects and participant outcomes, but no studies address EHR extraction for programmatic evaluations. We interviewed representatives of 9 grantees of the U.S. Department of Agriculture's Gus Schumacher Nutrition Incentive Grant Program's Produce Prescription Projects (GusNIP PPR) to understand their experiences with and capacity for utilizing EHR for evaluation. Five grantees planned to use EHR data, with 3 main strategies: reporting aggregate data from health clinics, contracting with external/third party evaluators, and accessing individual-level data. However, utilizing EHRs was prohibitive for others due to insufficient knowledge, training and/or staff capacity; lack of familiarity with the Institutional Review Board process; or was inappropriate for select target populations. Policy support for produce prescription programs requires a robust evidence base, deep knowledge of best practices, and an understanding of expected health outcomes. These insights can be most efficiently and meaningfully achieved with EHR data, which will require increased financial support and technical assistance for project operators.

How Does the Gus Schumacher Nutrition Incentive Program Work? A Theory of Change.

Increased fruit and vegetable (FV) intake is associated with decreased risk of nutrition-related chronic diseases. Sociodemographic disparities in FV intake indicate the need for strategies that promote equitable access to FVs. The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports state and local programs that offer nutrition incentives (NIs) that subsidize purchase of FVs for people participating in the Supplemental Nutrition Assistance Program (SNAP). While a growing body of research indicates NIs are effective, the pathways through which GusNIP achieves its results have not been adequately described. We used an equity-focused, participatory process to develop a retrospective Theory of Change (TOC) to address this gap. We reviewed key program documents; conducted a targeted NI literature review; and engaged GusNIP partners, practitioners, and participants through interviews, workshops, and focus groups in TOC development. The resulting TOC describes how GusNIP achieves its long-term outcomes of increased participant FV purchases and intake and food security and community economic benefits. GusNIP provides NIs and promotes their use, helps local food retailers develop the capacity to sell FVs and accept NIs in accessible and welcoming venues, and supports local farmers to supply FVs to food retailers. The TOC is a framework for understanding how GusNIP works and a tool for improving and expanding the program.

Food System Workers are the Unexpected but Under Protected COVID Heroes.

Coronavirus disease 2019 (COVID-19) poses an occupational health risk to food system workers including farmers/producers, grocery store workers, emergency food system staff and volunteers (e.g., food pantry workers), and others. These food system workers have been pushed to the front-line of this pandemic, providing essential services that support food consumption for all Americans. Food system workers are some of the most economically vulnerable populations and are at risk of further financial disparities and contraction of COVID-19 during this pandemic. As we continue to grapple with the best strategies to support the food system and mitigate concerns around the spread of COVID-19, appropriate measures must be considered to better protect and support front-line food system workers that safeguard food access for all Americans.