Non Technical Summary
NY Fresh Rx is a collaborative project between Cornell Cooperative Extension of NassauCounty (CCE Nassau), Harmony Healthcare Long Island (HHLI), a Federally Qualified HealthCenter, and Hofstra University. Over the course of this multi-year project, NY Fresh Rx willprovide a six-month home delivered CSA box style produce prescription to 350 low-income,food-insecure households who access care at HHLI's Hempstead and/or Roosevelt locations andhave one or more documented, diet-related chronic conditions: T2DM, CVD, and/or Obesity.Fresh produce will be supplied by CCE Nassau's local farm and other Long Island basedfarmers, thereby supporting sustainable food production and local economies. Additionally,nutrition education programming will be offered to all NY Fresh Rx participants.This program model was designed to reduce and/or remove two identified barriers tohealth - affordability and transportation. NY Fresh Rx will evaluate the effectiveness of thismodel for improving food security, dietary behaviors, and health outcomes for low-incomeindividuals in the ethnically and racially diverse communities of Hempstead and Roosevelt (inNassau County, NY). Research partners from Hofstra University will provide leadership for arobust evaluation process that will not only examine participant outcomes but will also examinethe impact on healthcare use and associated costs.

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6099	1010	50%
724	6099	1010	50%

Knowledge Area
703 - Nutrition Education and Behavior; 724 - Healthy Lifestyle;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
1010 - Nutrition and metabolism;

Goals / Objectives
The overarching goal of NY Fresh Rx is to evaluate the effectiveness of a home delivered CSA Box style produce prescription for improving food security, dietary behaviors, and health outcomes for low-income individuals in the ethnically and racially diverse communities of Hempstead and Roosevelt while supporting sustainable food production and local economies.Over the course of this multi-year project, NY Fresh Rx will provide produce prescriptions to 350 low-income, food-insecure individuals who access care at HHLI's Hempstead and/or Roosevelt centers and who have one or more documented, diet-related chronic conditions: T2DM, pre-diabetes, CVD, and/or Obesity.The objectives of the program are to:(1) Enroll at least 350 participants over two seasons in NY Fresh Rx. (2) Provide a bi-weekly "CSA style" boxed produce prescription valuing approx $18-20 wholesale per box.(3) Improve the dietary health of participants through increased consumption of fruits and vegetables. (5) Support local food systems. (6) Promote healthy behavior change in program participants through nutrition education programs.(7) Create strong community partnerships. NY Fresh Rx will provide participants with a CSA style box of fresh fruits and vegetables on a biweekly basis via either a) home delivery, or b) pick-up at a convenient, centrally located location in the community. The rationale for using a "home delivery" model is to remove a primary barrier to health as identified in Nassau County's most recent Health Assessment, articulated by our health partner (HHLI), and one we've experienced with our mobile market program and participation in the Veggie Van study:Transportation.The rationale for the program duration (4-6 months) relates both to the growing season here in Long Island, NY, and to the fact that changes in health data can be detected at about 4 months, specifically HgbA1c, a marker to evaluate T2DM. Rationale for a bi-weekly delivery schedule is to help minimize food waste. Each box will contain safe storage instructions to help participants maximize the freshness of the produce over the two-week period.Because of our relationships with local farms, we are able to purchase seasonal items wholesale and in bulk. Participants will receive approximately $18-20 wholesale dollars' worth of fresh local produce on a biweekly basis.The retail value of the produce being provided ranges from $30-$40. By basing the cost of each prescription box on the wholesale value, instead of using a voucher or retail card for participants to purchase produce on their own, we are able to provide significantly more fresh fruits and vegetables.

Project Methods
(1) Enroll at least 350 participants over two seasons in NY Fresh Rx. Each produce prescription will be provided for 4-6-months via home delivery (or option to pick-up at convenient locations close to participants' homes) during our growing season which is approximately May through December. During the first season, we intend to enroll 150 participants. During the second season, we intend to enroll 200.We will track process measures including, but not limited to, number of participants referred, number enrolled, and number of produce prescriptions distributed.We understand that a minimum of 100-130 participants are required to complete both pre and post surveys in order for a statistically significant detection of a ¼ cup change in fruit and vegetable consumption to be obtained. Completion of surveys will be incentivized with a $10 cash card.(2) Provide a bi-weekly "CSA style" boxed produce prescription valuing approx $18-20 wholesale per box. By offering home delivery (or community pick-up) for the produce prescription, we will reduce access barriers by providing a consistent source of fruits and vegetables. In addition to the process measures identified in the evaluation section, we will also track the food items included in each box, and will continually evaluate our distribution process in order to make improvements in real time. Participant satisfaction will also be routinely evaluated. Surveys will be included, periodically, in the produce box. Participants can complete the survey through an electronic portal (accessible on-line/ QR Code) or by paper. The surveys will offer participants the opportunity to list items they would like to receive (or not receive) in future deliveries, identify barriers to use of their produce, and suggest solutions.(3) Improve the dietary health of participants through increased consumption of fruits and vegetables. The following health care measures will be tracked: change in BMI, BP, HgbA1c, and lipid profile (LDL, TG, HDL,TC) at baseline and at program completion. Our healthcare partner, HHLI, will provide HIPPA compliant, de-identified data for program participants. Fruit and vegetable intake will be assessed at baseline and at completion of the program via surveys administered during the enrollment process and at the end of the 6-month program period (described more in the evaluation section). Additionally, we will employ the use of a Veggie Meter to measure skin carotenoids, which have been shown to be an effective biomarker associated with fruit and vegetable intake, at baseline and at completion.(4) Reduce individual and household food insecurity. Through pre and post participation surveys, we will assess and evaluate food insecurity, fruit and vegetable intake, stress, and diet related behaviors. Specifically related to household food insecurity, we will use the Hunger Vital Sign 2-question screening tool and/or the USDA's FSSM 6-item short form. Surveys will be collected in a number of ways including electronic portals and paper. Cash gift cards valuing $10 each (one card at baseline and one at program completion for a total of $20) will be provided to incentivize participants to complete the surveys.(5) Support local food systems. In addition to our production farm providing produce for NY Fresh Rx, we have established relationships with and will source produce from many Long Island growers. Sourcing from our local farms will support our local food system.(6) Promote healthy behavior change in program participants through nutrition education programs. In addition to assessing hard metrics and health data, we will track dietary behavioral outcomes through pre- and post- surveys that ask about fruit and vegetable intake, junk food consumption, and eating at any type of restaurant including fast food, as well as mealtime practices such as preparing foods from scratch, use of nutrition facts labels to make purchasing decisions, etc. Additionally, our staff of nutrition educators will provide nutrition education on a variety of topics including Diabetes Self-Management, Heart Healthy Eating, DASH Diet, Nutrition Facts Labels, Food Safety, Recipe Modifications, Cooking Demos, and more. Nutrition education will be provided in both English and Spanish and other languages as needed and will be provided in person and via zoom at least twice a month. These programs will continue after the implementation period to maintain engagement with participants. Incentives will be provided to encourage participation.(7) Create strong community partnerships. As a result of our work preparing for this grant opportunity, CCE Nassau has strengthened our existing relationship with HHLI and with Hofstra University. We have also forged a new partnership with AHRC, a program for individuals with intellectual and developmental disabilities, whose participants will benefit from vocational training opportunities.In support of NTAE's cluster evaluation model, CCE Nassau will collect all necessary data to comply with the reporting requirements including but not limited to a process analysis, an outcome analysis, and a comparative analysis.In addition to participant surveys, we will rely on HHLI's EHR, eClinicalWorks, and their population health database, Azara, to collect relevant participant health metrics and demographics.We will be employing a longitudinal study design with a mixed method research model. We will examine both quantitative and qualitative metrics gathered at baseline and then again at the completion of the program.The health conditions of interest and identified by our healthcare partner include Diabetes, Cardiovascular Disease, and Obesity. As such, health outcomes that will be measured at baseline and after completion of the program include: HgbA1c, BMI, Lipid Profile, and BP. We will also use validated tools to measure stress and/or anxiety via the GAD7 and/or the PSS-4. Additionally, we will employ the use of a Veggie Meter, a non-invasive device applied to a finger that measures skin carotenoids, regardless of skin color, which has been shown an effective biomarker associated with fruit and vegetable intake, at baseline and at completion. We will also work with our PIs and NTAE to determine the best way to measure changes in F&V consumption (the 10-item F&V intake DSQ) and to assess change in food insecurity (the 6-Item Short Form USDA-FSSM). Finally, we will work with HHLI to collect and assess healthcare utilization by our cohort (compared to cohort not enrolled) in order to determine if the program was able to impact healthcare costs. Our analysis will focus on an overall outcome assessment that documents the project's effectiveness in (a) improving dietary health through increased consumption of fruits and vegetables; (b) reducing individual and household food insecurity; and (c) reducing healthcare use and associated costs among eligible participants.?We expect to gain insight into the effectiveness of our model which involves providing a defined "dose" (a $18-$20 wholesale value) box of fresh produce. We are interested in evaluating this "dose" as both an effective model and as an effective amount - does this amount of produce impact the quantitative and qualitative measures of interest? From a process perspective, does this model serve the needs of the target community? Is it a replicable and sustainable model? Additionally, we will assess home delivery as an effective strategy in a low-income suburban area with both transportation barriers and limited access to fresh produce. These questions will be answered through carefully constructed questionnaires for all participants and follow-up "exit interviews" with a sampling of participants.