Source: HEALTH, WASHINGTON STATE DEPARTMENT OF submitted to
WASHINGTON STATE DEPARTMENT OF HEALTH FINI GRANT PROJECT
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
TERMINATED
Funding Source
OTHER GRANTS
Reporting Frequency
Annual
Accession No.
1006162
Grant No.
2015-70018-23357
Project No.
WN.W-2015-02692
Proposal No.
2015-02692
Multistate No.
(N/A)
Program Code
FLSP
Project Start Date
Apr 1, 2015
Project End Date
Mar 31, 2020
Grant Year
2015
Project Director
Auvinen, A.
Recipient Organization
HEALTH, WASHINGTON STATE DEPARTMENT OF
101 ISRAEL RD SE
OLYMPIA,WA 98501
Performing Department
(N/A)
Non Technical Summary
Washington State has 37,249 farms, and agriculture contributes 13 percent to the state economy. Rich soils, a diversity of favorable regional climates, and large-scale irrigation make Washington one of the most productive growing regions in the world, enabling farmers to produce some 300 crops each year. Approximately 120 fruit and vegetable crops grown on 800,000 acres include highly nutrient-dense varieties emphasized by the Dietary Guidelines for Americans, 2010. Western Wa.produces an abundance of dark, leafy greens, carrots and winter squash varieties. Growers in northwest Wa.specialize in blueberries and raspberries and bring to market broccoli, cauliflower, salad greens and leeks. Eastern Wa., with its longer, sunny summers, produces crops high in antioxidants such as red peppers, tomatoes, onions, garlic and hot peppers. Washington leads the country in the production of apples and pears--available year-round--and central Wa. provides nectarines, plums and pluots. Farmers markets (FMs) play a vital role in direct consumer marketing and sales of fruits and vegetables (F/V); over 160 FMs in towns and cities allow consumers to purchase produce directly from farms. Nationally, Washington ranks eighth for direct- to-consumer farm sales.Despite its agricultural bounty, household food insecurity is unacceptably high in Wa., and the state struggles to meet the needs of its hungry people. Nearly fifteen percent of Wa. households struggle with food insecurity and rates of hunger remain persistently and unacceptably high. Data show that in Wa., 6.1 percent of the population experience chronic hunger, and this average rate of hunger is one-half point higher than the national average of 5.6 percent.Washington StateDepartment of Healthinvestigators found that eating F/V less than once daily is strongly associated with food insecurity. Of pressing concern are the 575,000 Washington residents (11 percent) who eat less than one serving of F/V daily. Research led by community-based organizationsconfirms that economically distressed households simply cannot afford to buy healthy food, given their limited grocery budgets. Meanwhile, Wa. is one of only three states in which poverty increased last year. According to a recent U.S. Census Bureau Report, in 2013, 14.1 percent of Washingtonians (967,282 people) were living in poverty, compared to 13.5 percent (915,278 people) in 2012.Washington State Department of Health's Food Insecurity Nutrition Incentive (FINI) Project aims toimprove the nutritional status of households participating in the Supplemental Nutrition Assistance Program (SNAP) through a number of strategies, focusing in areas of the statewherethe burden of poverty, food insecurity and poor nutrition are highest. With funding from the National Institute of Food and Agriculture at the U.S. Department of Agriculture, the Department willoffera variety of cash incentives to SNAPshoppersat supermarkets and farmersmarketsto increasetheir purchases of a variety of fruits and vegetables. To maximize impact, the Department willlaunch a social marketing and promotional campaign to raise awareness about the incentive programs. It will alsoleverage a broad network ofcollaborators fromstate and local government, social service agencies, foundations, universities,healthcare,the grocery industry, and local farmers markets.This project will expand theFresh Bucksprogram to over 80farmers markets statewide. Fresh Bucks isa nutrition incentive program that incentivizes SNAP shoppers to purchasefruit andvegetablesat farmers markets. At participating markets, when SNAP shoppers swipe their EBT card at the information booth, they are offered an incentive - extra value on top of the value redeemed with SNAP - to purchase additional fruits and vegetables. Incentive values vary from market to market - from a $2 for $2 incentive up to $10.Similarly, Safeway supermarkets throughout Washington willoffercash incentives atthe point-of-saleto SNAP shoppers to increase their purchases offresh, canned or frozenfruits and vegetableswith no added fats, sugars, or salt.Safeway Inc. is a Fortune 500 company which operates over 1,300 store locations in 20 states, including SNAP-authorized brick and mortar stores serving over 2 million SNAP households nationally. The largest concentration of Safeway branches is in Washington with 168 stores.Safeway will tapinto its business relationship with Catalina, apersonalized digital mediacompany, to offer $3 incentives for every $10 purchase of eligible fruits and vegetables. The$10 fruit and vegetable"prescription" vouchers will also be redeemable at Safeway stores.Finally, the Department ispartnering with several community-based health systems to provide$10 fruit and vegetable "prescription" vouchersredeemableat Safeway supermarkets and farmers markets when a SNAP shopper makes a qualifying purchase. Healthcare providers, community health workers,and community-based nutritionistswill "prescribe" the vouchers during evidence-based nutrition counseling, education and services.Participating health systems include MultiCare, Yakima Valley Memorial Hospital, and UnitedHealthcare Community Plan. The Food Insecurity Nutrition Incentives (FINI)project is important to Wa.Of the roughly $6 million in federal funds awarded, nearly 60 percent ($3.5 million)will be directed for fruit and vegetable cash incentives for low-income households participating in SNAP. This infusion of cash is expected to increase the purchases of fruits and vegetables by SNAP shoppers, and could also generate an estimate $6 million in local economic activity. (Moody's Analytics estimates that every dollar increase in SNAP benefits generates about $1.70 in economic activity.)
Animal Health Component
0%
Research Effort Categories
Basic
50%
Applied
50%
Developmental
(N/A)
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
6046299301033%
6077410301033%
9017410301034%
Knowledge Area
901 - Program and Project Design, and Statistics; 604 - Marketing and Distribution Practices; 607 - Consumer Economics;

Subject Of Investigation
6299 - Marketing, general/other; 7410 - General technology;

Field Of Science
3010 - Economics;
Goals / Objectives
The primary goal of Washington State Department of Health'sFood Insecurity Nutrition Incentives (FINI) project is to improve the nutritional status of households participating in the Supplemental Nutrition Assistance Program (SNAP) by: (1) incentivizing, and thus increasing,fruit and vegetablepurchases; (2) executing multiple, targeted marketing strategies aimed at increasingfruit and vegetablespurchases; and (3) enhancing the role of food retailers and community partners to support SNAP participants and the SNAP program.To achieve this goal, the Department and its collaborators have identified five major objectives:1. Design, implement and test SNAP fruit and vegetable incentives and point-of-sale delivery methods in multiple retail venues (FMs, CSA, supermarkets) and geographic locations, focusing on effective and efficient benefit redemption technologies.2. Increase the purchase offruits and vegetablesby SNAP participants by providing incentives at the point-of-purchase, focusing on effective and efficient benefit redemption technologies.3. Implement provider-to-patient, community health worker (CHW)-to-client, peer-to-peer, and community engagement strategies to refer, promote, and recruit for incentive programs.4. Implement evidence-based behavior change strategies during individual and group counseling and education.5. Develop, plan, implement, and evaluate the project activities in direct partnership with residents and community-based organizations of/in low-income, underserved areas.
Project Methods
The Department and its collaboratorswill implement and evaluate multiple incentives programs in a variety ofvenues. outlined in thetable below:Table. Types of incentives, eligible fruits and vegetables (F/V), currency, and location of distribution and redemption, by type of retail venue.Retail venueIncentive TypeEligible F/VCurrencyLocation of Distribution and Redemption86 farmers markets/community-supported agriculture1 small, independent grocer (i.e. Delridge Co-op in Seattle)Dollar-for-dollar match up to $10$2 incentive on $5 purchase (no maximum)Fresh and/or dried F/V and edible plant startsWooden token, scrip, voucherDistributed at FMs, redeemed at point of purchase"Prescription" (Rx) for F/V ($10 voucher)Rx (voucher)Rx distributed by providers, community health workers (CHWs), or community nutritionists at clinic appointments or during nutrition classes; redeemed at point of purchase$5 voucher (up to $20)VoucherVouchers distributed at the end of nutrition classes or to SNAP Ambassadors who participate in outreach; redeemed at point of purchase168 Safeway supermarkets$3 incentive on $10 purchase of eligible F/VFresh, canned or frozen F/V with no added fats, sugars, or salt.CouponOffered and redeemed at the cash register"Prescription" (Rx) for F/V ($10 voucher)Fresh F/VRx (voucher)Distributed by providers, CHWs, or community nutritionists at clinic appointments or during nutrition classes; redeemed at point of purchaseDescription of large-scale project management activities. The Department'sfirst activity will be for project directors to convene the Advisory Network for an opening summit. This cross-sector network of state and local government agencies, health systems, foundations, universities, and nonprofit organizations will provide essential expertise and assist with strategy development, technical assistance and sustainability planning throughout the project. With this Network and the lead implementing agencies (LIAs), the Department willfinalize state and local workplans and partner roles.The Department willprovide coordinated support for the project including financial management systems, administration, technical assistance, partner engagement, communication, data collection, and monitoring and evaluation.Description of farmers market (FMs)and CSA activities. LIAs managing Fresh Bucks at FMs and CSAs will meet early in the project with their strategic partners to map out consistent and coordinated implementation within and across regions and strategies. Strategic discussions about how best to coordinate a state-level Fresh Bucks program are already underway. A second key activity early in the project willbe to design, develop, and test a mobile app for use in tracking EBT sales and incentives. Within the first three months, City of SeattleOffice Office of Sustainability and Environmentwill identify a software developer to design a tablet-based app capable of tracking EBT transactions, incentives, and shopper frequency at FMs. Meanwhile,Washington State Farmers Market Association willwork with FMs and CSA that do not accept EBT to apply for an FNS number and equipment. FMS will collaborate with strategic partners and SNAP "Ambassadors" (SNAP participants) to conduct outreach and host market events such as cooking demonstrations, gardening opportunities, and family events. Fresh Bucks programs will vary their incentive ratios across regions (see the table above).Description of supermarket Activities.TheDepartment willmanage the relationship with Safeway Inc. and Safeway Foundation to design and develop the supermarket incentive program. Using Catalina, a personalized digital media company for Food Brands, Grocery, Mass and Drug Retailers,Safeway Inc. will engage SNAP shoppers personally and digitally--across a range of networks including mobile, online and in-store--with incentives designed to increase purchases of fresh, canned or frozen F/V with no added fats, sugars, or salt. A key activity at the outset would be for Safeway Inc. and Catalina to modify their systems to track EBT sales of target F/V and to offer the incentive (see table above).Eligible F/V will be programmed into Safeway/Catalina systems by unique produce code (UPC) to ensure the FINI Grant funds will only be used to incentivize canned, frozen, and fresh produce items that do not include added sugars, fats or salt. Once the system is established,the Department willwork with Safeway Inc. and Catalina to design personalized coupons based on past (up to 3 years), current, and future buying behavior. Safeway will also modify its system to be capable of redeeming the F/V Rx vouchers distributed by healthcare providers, CHWs,caseworkers, and community nutritionists. Meanwhile, Safeway Foundation will design and print the F/V Rx vouchers and, once ready,the Department willdistribute these to the appropriate LIAs. Safeway Foundation will host a minimum of 12 in-store events featuring store tours, cooking demonstrations, and samples to promote the use of the incentives.Description of fruit and vegetable Rx activities.The Department willpartner with several community-based healthcare providers to provide F/V Rx incentives to SNAP participants (see table above). F/V Rx will be "prescribed" by healthcare providers, CHWs, caseworkers, and community nutritionists during existing evidence-based, multi-dimensional nutrition and healthy eating counseling, education and services. SNAP participants willbe able to redeem their F/V Rx ($10 vouchers) at participating FMs or any Safeway store to buy fresh F/V when they make a qualifying SNAP purchase. One of the first activities for the LIAs managing F/V Rx programs willbe to revise their systems for tracking participation in various chronic disease prevention programs in order to track who, among those participating in these behavior-change programs, is also a SNAP participant (and thus is eligible to receive F/V Rx). UnitedHealthcare and MultiCare Health System are both exploring the feasibility of modifying their electronic medical record systems to track SNAP participation and F/V Rx. Meanwhile, LIAs would train the providers, CHWs, and community nutritionists on the incentive program and redemption/tracking methods.Description of evaluation activities. To meet the rigorous evaluation requirements for this large-scale project, the Department willfhre a Research Investigator who would be dedicated full-time to design and oversee the rigorous process and outcome evaluations for the Safeway incentive program and the F/V Rx program. The RI will also cooperate with USDA's independent evaluators and facilitate access to lead implementing agencies and project sites.The Department will alsocontract with Universityof Washington Center for Public Health Nutrition (UW-CPHN)whichwill lead all aspects of data collection and evaluation for Fresh Bucks (the farmers market incentive program). The Department RI and UW-CPHN will develop data collection, monitoring and evaluationplans in accordance with USDA's independent evaluator and requirements.

Progress 04/01/15 to 03/31/20

Outputs
Target Audience:The primary target audience for this project are Washingtonians who participate in the Supplemental Nutrition Assistance Program (SNAP). By providing monthly benefits to eligible low-income individuals and families, SNAP plays a critical role in improving food and nutrition security and child and adult health. During the 2019 state fiscal year, an average of 841,927 people accessed Washington's Basic Food Program, aka SNAP, (a 6.2% decrease from state fiscal year 2018); 34% of Basic Food recipients were children. Washington State Department of Health (DOH) and its FINI implementing partners used three main strategies to distribute $5,270,580 worth of fruit and vegetable incentives to SNAP participants. The target audience reached during this project period (April 1, 2015 - March 31, 2020) are summarized below, by incentive strategy. FARMERS MARKET MATCH: Ninety-the (93) farmers markets in 21 counties offered SNAP incentive programs. SNAP incentive programs were available in densely-populated metropolitan areas (i.e. City of Seattle), as well as rural cities and counties in central, eastern, and western WA. Participating markets served 25,219 unique SNAP customers and 8,834 repeat SNAP customers during the project period. PRODUCE PRESCRIPTIONS: Three produce prescription models were supported by DOH's FINI project: Fresh Bucks Rx, Complete Eats Rx, and Small Steps. Fresh Bucks Rx was run by City of Seattle Office of Sustainability and Environment working with King County farmers markets, six ethnic retail stores, 17 supermarkets, and six Seattle-based health systems that serve racially/ethnically diverse patient populations with a high percentage of Medicaid and uninsured patients. The target audience is SNAP patients who screen positive for food insecurity. Some clinics are also screened for nutrition-related chronic disease as a criteria for produce prescription eligibility. Fresh Bucks Rx served more than 1,665 patients or families during the project period. Complete Eats Rx was administered by DOH working with Albertsons Co. (DBA Safeway) and 11 health systems. The target population was SNAP clients in participating clinics or home visiting programs, chronic disease prevention and management programs, and SNAP-Ed classes or events. Complete Eats Rx served8,787 SNAP clients during the project period (excludes clients who are not Loyalty Club Card holders). Small Steps was a program run by UnitedHealthcare Community Plan. The target audience was SNAP clients who are also Medicaid eligible/Medicaid-Medicare eligible low-income seniors. Small Steps served 5,246 SNAP clients during the project period. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: 169 large-chain (Safeway) grocery stores in 30 counties offered the SNAP incentive program Complete Eats. The programwas run by Safeway and targets SNAP shoppers who use their EBT and Loyalty Club Card to purchase fruits and vegetables. Changes/Problems:Complete Eats did not operate from August 1 - December 1, 2018 because the program ran out of federal FINI funding much quicker than expected (12 months earlier than planned). Private funding for Complete Eats was secured to restart the program in December 2018, and state funding was used to keep the program operating. UHCCP's Small Steps stopped at the end of 2018 because of staffing changes. The produce prescription program did not operate in 2019. What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?Department of Health (DOH) utilized a variety of communication tools and tactics to disseminate results to communities of interest. Two DOH webpages (www.doh.wa.gov/FINI and www.doh.wa.gov/CompleteEats) provide information about the FINI project and incentive programs to stakeholders, SNAP clients, and the general public. Fact sheets, data briefs, a progress report and other materials are available on the webpages. DOH staff presented about its FINI project at five conferences (three national, two state). Information was also provided to the Governor's Council for the Healthiest Next Generation initiative and throughout the 2019 and 2020 Washington State Legislative sessions, as it related to state funding for SNAP incentive programs. The FINI project was discussed at site visits hosted by Advisory Network members (DOH not involved). DOH published information about FINI programs through social media posts. DOH's FINI implementing partners and Advisory Network partners disseminated results statewide and local activities. For example, Northwest Harvest (an Advisory Network member) hosted FINI participant stories on their website in January 2019. This was an opportunity for participants to share their experience with FINI programs to decision-makers and peers. At the local level, Yakima Valley Farm Workers Clinics participated in two media appearances to promote the Complete Eats Rx program as their clinic services and programs. For more information, see also PRODUCTS and OTHER PRODUCTS. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? Under Washington's FINI grant, $5,270,580 worth of fruit and vegetable incentives were redeemed by participants in the Supplemental Nutrition Assistance Program (SNAP) at farmers markets and grocery stores. Department of Health tested three types of SNAP nutrition incentive programs: Farmers Market Match - When customers spent their SNAP benefits at participating farmers markets, they received additional tokens or vouchers to spend on fruits and vegetables at the market.93 farmers markets in 21 counties offered SNAP incentive programs. Markets processed 130,759 SNAP transactions, valued at $2,069,202, and redeemed $1,609,133 in SNAP incentives. The total value of SNAP and SNAP incentives redeemed at participating farmers markets was $3,678,334 with 25,219 unique SNAP customers served. Produce Prescriptions -16 health systems prescribed fruits and vegetables to SNAP participants. The prescription is a paper voucher that recipients can use like cash to buy fruits and vegetables at farmers markets and grocery stores. 10,452 SNAP clients redeemed $911,342 worth of produce prescriptions atfarmers markets and grocery stores. Complete Eats - In 169 Safeway stores, shoppers who bought at least $10 worth of qualifying fruits and vegetables received a coupon for $5 off their next purchase of the same. Complete Eats launched in June 2017, and SNAP clients redeemed $2,750,105 worth of coupons. OBJECTIVES #1, #2: FARMERS MARKET MATCH: Three farmers market incentive programs were supported by DOH's FINI grant: Fresh Bucks, Fresh Match, and Double Up Bucks. DOH used a regional lead model to implement FINI activities and incentive in farmers markets across Washington. Catholic Charities of Spokane (CCS), Washington State University - Clark County Extension (WSU), MultiCare Health System, City of Seattle Office of Sustainability and Environment (OSE), Skagit Valley Farmers Market Coalition (SVFMC), and Kitsap Public Health District (KPHD), and Olympia Farmers Market (OFM) managedSNAP incentive programs in their respective regions. Ninety-three (93) farmers markets in 21 counties offered SNAP incentive programs in 2019.Markets processed 130,759 SNAP transactions valued at $2,069,202 and redeemed $1,609,133 in SNAP incentives (SNAP transactions and incentives totaled $3,678,334). Participating markets served 25,219 unique SNAP customers and 8,834 repeat SNAP customers during the reporting period. An online participant-level survey showed85%of survey respondentsindicated they eat more fruits and vegetables, and 61% report their family members eating more fruits and vegetables as a result of the program. PRODUCE PRESCRIPTIONS: Three produce prescription models weresupported by DOH's FINI grant: Fresh Bucks Rx, Complete Eats Rx, and Small Steps. 16 health systems prescribed fruits and vegetables to SNAP clients. DOH implemented an online patient-level survey (2017-2019) for SNAP clients who received Rx vouchers. Ninety percent of respondents indicated that they eat more fruits and vegetables as a result of the Rx program, and 84% said they are less likely to run out of food as a result of the Rx program. Key programmatic results are described below. Fresh Bucks Rx - City of Seattle Office of Sustainability and Environment partnered with King County farmers markets and six ethnic grocery stores to offer Fresh Bucks Rx 6 health systems. These health systems issued $420,050 worth of produce vouchers; $263,102 (63%) were redeemed by 1665 patients at 50 farmers markets and grocery stores. Complete Eats Rx - DOH partnered with Safeway to offer Fruit and Vegetable Prescriptions ($10 vouchers). By the end of the FINI project period, 11 health systems offered Complete Eats Rx.These health systems issued $955,560 worth of produce vouchers; $595,780 (62%) were redeemed by 8,787 unique club card holders at grocery stores. Small Steps - UnitedHealthcare Community Plan (UHCCP) partnered with Federally Qualified Health Centers and WIC clinics to offer $10 vouchers for a local farmers market where they can select fruits and vegetables. SNAP participants redeemed 5,246 vouchers (worth $52,460) at farmers markets. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: DOH and Safeway operated Complete Eats. SNAP shoppers who spent $10 on fruits and vegetables with their EBT and Loyalty Club Card received a $5 coupon for fruits and vegetables. The program operated from June 2017 - July 2018 (ran out of federal funding) and relaunched in December 2018 with funding from the Michael and Susan Dell Foundation and Washington state appropriations for the 2019-2021 biennium. During the FINI grant, 169 grocery stores in 30 counties offered Complete Eats. 2,214,083 coupons were issued at participating stores; and 550,021 coupons were redeemed (25%) valued at $2,750,105. OBJECTIVES #3, #4: FARMERS MARKET MATCH: Regional leads targeted community outreach and education about farmers market incentivesto a variety of organizations that serve SNAP populations. Many of the farmers market lead organizations presented to staff at Community Service Offices, CSOs, (application office for SNAP benefits) about utilizing farmers market incentives and lead organizations distributed linguistically-appropriate promotional materials. PRODUCE PRESCRIPTIONS: Sixteen health systems issued produce prescriptions in tandem with a variety of nutrition education and behavior change strategies. Health systems partners reported the voucher was a useful tool to engage patients/clients in educational and counseling sessions since it provides economic support that helps patients achieve healthy eating goals. Partners anecdotally reported no-show rates decreased for appointments in which the voucherwas issued, and chronic disease managementclass increased. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: DOH coordinated with dozens of statewide and local partners to promote the Complete Eats program, using flyers and recipe cards that detailed the incentive. More than 50 CSOs (application office for SNAP benefits) provided promotional materials and information to SNAP clients. SNAP-Ed local contractors throughout the state promoted the Complete Eats program as it connected with their nutrition education services. DOH partnered with the state WIC office to offer Complete Eats materials to more than 200 local WIC offices throughout the state. DOH utilized social media to promoteComplete Eats. OBJECTIVE #5: FARMERS MARKET MATCH: DOH coordinated with the regional leads to promote an online survey to assess how SANP incentives impact recipients' consumption of fruits and vegetables, food security, and self-reported nutrition goals. Seventy-nine percent (79%) of respondents indicated increased food security; 86% indicated they eat more fruits and vegetables as a result of SNAP incentives; and 78% report being better able to meet nutrition-related goals as a result of the SNAP incentive programs in farmers markets. PRODUCE PRESCRIPTIONS: DOH coordinated with health systems to promote an online survey to assess how produce prescriptions impact recipients' consumption of fruits and vegetables and self-reported health. Ninety-four percent (94%) of respondents indicated they eat more fruits and vegetables as a result of produce prescriptions; 84% report increased food security as a result of the prescription. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY:Shoppers who used Complete Eats coupons spent more on fruits and vegetables. During the first year of the Complete Eats program (Jun 2017-June 2018), Catalina reported to Safeway and DOH that SNAP customers who used Complete Eats coupons spent 15% more on fruits and vegetables (vs. the previous year when the program wasn't operating). During the second year of Complete Eats (December 2018 - September 2019), Catalina reported to Safeway and DOH that SNAP customers who used Complete Eats coupons spent 10% more on fruits and vegetables (vs. the previous year).

Publications

  • Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Marcinkevage J, Nambuthiri S, Igoe B. Washington States Large-scale FINI Project. Panel session presented at American Public Health Association Annual Conference; 2016 Oct. 29  Nov. 2; Denver, CO.
  • Type: Journal Articles Status: Published Year Published: 2016 Citation: Igoe B, McDermot D, Stahre M. Strengthening the Connection Between the Supplemental Nutrition Assistance Program and Farmers Markets. Prev Chronic Dis 2016;13:160186. DOI: http://dx.doi.org/10.5888/pcd13.160186.
  • Type: Journal Articles Status: Submitted Year Published: 2020 Citation: Riemer, Sophia, Walkinshaw, Lina, Auvinen, Alyssa, Marcinkevage, Jessica, Daniel, Mary. This Program is a Make or Break Scenario for Me: A qualitative Study on Participant Perceptions of a Supermarket Fruit and Vegetable Incentive Program. Journal of the Academy of Nutrition and Dietetics. Submitted March 2020.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Marcinkeavge, J. Fruit and Vegetable Coupons Increase Healthy Food Access for Low-Income Shoppers in Washington State. Panel session presented at American Public Health Association Annual Conference; 2019 November; Philadelphia, PA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Atkinson, B., Auvinen, A. Nutrition Prescription: Using Public-Private Partnerships to Develop Novel Food Insecurity Solutions. Presentation at Food and Nutrition Conference and Expo 2019; October 2019; Philadelphia, PA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Nambuthiri S, Marcinkevage J, Auvinen A. Washington State Farmers Market Incentive Programs Promote Purchase of Healthy, Local Food by SNAP Participants. Presentation at Council of State and Territorial Epidemiologists (CSTE) Annual Conference; 2018 June 10-14; West Palm Beach, FL.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Marcinkevage J, Nambuthiri S, Auvinen A. Fruit and Vegetable Prescriptions Improve Access to Healthy Foods Among Food Insecure IndividualsWashington State, 2016-17. Presentation at Council of State and Territorial Epidemiologists (CSTE) Annual Conference; 2018 June 10-14; West Palm Beach, FL.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Auvinen A, Marcinkevage J, Nambuthiri S. Public Health Implications of a Large-Scale Multi-Sector Produce Prescription Program. Panel session presented at American Public Health Association Annual Conference; 2018 November 13; San Diego, CA.
  • Type: Journal Articles Status: Published Year Published: 2019 Citation: Marcinkevage J, Auvinen A, Nambuthiri S. Washington States Fruit and Vegetable Prescription Program: Improving Affordability of Healthy Foods for Low-Income Patients. Prev Chronic Dis 2019;16:180617. DOI: http://dx.doi.org/10.5888/pcd16.180617
  • Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Wells J, Auvinen A, Teske C. Charting the Course for Food Access Programs in 2019 and Beyond. Presentation at Washington State Farmers Market Conference; 2019 March 22; Walla Walla, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Nambuthiri S, Marcinkevage J, Igoe B. Washington State Food Insecurity Nutrition Incentives (FINI) Initiative: Year 1 Update. Poster session at Council of State and Territorial Epidemiologists (CSTE) Annual Conference; 2017 June 4-8; Boise, ID.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Tong Morrow K. Washington States FINI Project. Panel session at Association of SNAP Nutrition Education Administrators (ASNNA) Conference; 2018 Feb. 8; Arlington, VA.
  • Type: Websites Status: Published Year Published: 2016 Citation: Washington State's Food Insecurity Nutrition Incentive Grant webpage: www.doh.wa.gov/FINI.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Auvinen A and Wells J. Washingtons FINI Grant. Presentation at Washington State SNAP-Ed Forum; 2018 March 28; Seattle, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Auvinen A and Jacobson M. Fruit and Vegetable Rx: A Nexus for Health Care, Public Health and the Food System. Presentation at the Washington State Public Health Association Conference; 2018 October 17; Wenatchee, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Auvinen A. Washington States Food Insecurity Nutrition Incentive (FINI) Grant. Panel session presented at Seattle Childrens Hunger Symposium.; 2016 Dec. 3; Seattle, WA.
  • Type: Other Status: Published Year Published: 2016 Citation: NEWSLETTER - Igoe B. Washington Healthcare Providers are Now Prescribing Fruits and Vegetables. Washington Nursing Commission News. Summer 2016; Volume 10; Edition 25.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Flores K and Igoe B. Synergies between Washington States Food Insecurity Nutrition Incentive Project & WIC Farmers Market Nutrition Program. Oral presentation at the National Association of Farmers Market Nutrition Program Annual Conference; 2016 Sept. 9; Juneau, AK.


Progress 04/01/18 to 03/31/19

Outputs
Target Audience:The primary target audience for this project are Washingtonians who participate in the Supplemental Nutrition Assistance Program (SNAP). By providing monthly benefits to eligible low-income individuals and families, SNAP plays a critical role in improving food and nutrition security and child and adult health. During the 2017 state fiscal year, 1,270,627 people accessed SNAP in Washington (SFY2018 not available); 460,552 (36%) whom were children. Among all SNAP clients in Washington, 21% were Hispanic; 13% were Black/African American; 9% were Asian/Pacific Islander; 7% were American Indian/Alaska Native. Washington State Department of Health (DOH) and its FINI implementing partners are using three main strategies to offer incentives to SNAP participants so they can afford more fruits and vegetables. The target audience reached during this reporting period (April 1, 2018 - March 31, 2019) are summarized below, by incentive strategy. FARMERS MARKET MATCH: Ninety-two (92) farmers markets in 21 counties offered SNAP incentive programs. SNAP incentive programs are available in densely-populated metropolitan areas (i.e. City of Seattle), as well as rural cities and counties in central, eastern, and western WA. Participating markets 12,332 unique SNAP customers and 2,850 repeat SNAP customers during the reporting period. PRODUCE PRESCRIPTIONS: Three produce prescription models are supported by DOH's FINI project: Fresh Bucks Rx, Complete Eats Rx, and Small Steps. Fresh Bucks Rx is run by City of Seattle Office of Sustainability and Environment working with King County farmers markets, six ethnic retail stores, 17 supermarkets, and six Seattle-based health systems that serve racially/ethnically diverse patient populations with a high percentage of Medicaid and uninsured patients. The target audience is SNAP patients who screen positive for food insecurity. Some clinics are also screening for nutrition-related chronic disease as a criteria for produce prescription eligibility. Fresh Bucks Rx served 477 unique patients or families during the reporting period. Complete Eats Rx is run by DOH working with Albertsons Co. (DBA Safeway) and 8 health systems. The target population is SNAP clients in participating clinics or home visiting programs, chronic disease prevention and management programs, and SNAP-Ed classes or events. Complete Eats Rx served 5,926 SNAP clients during the reporting period (excludes clients who are not Loyalty Club Card holders). Small Steps is a program run by UnitedHealthcare Community Plan. The target audience is SNAP clients who are also Medicaid eligible/Medicaid-Medicare eligible low-income seniors. Small Steps served 1,413 SNAP clients during the report year. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: 169 large-chain (Safeway) grocery stores in 30 counties offered the SNAP incentive program Complete Eats. The program is run by Safeway and targets SNAP shoppers who use their EBT and Loyalty Club Card to purchase fruits and vegetables. Changes/Problems:Private funding for Complete Eats is expected to be fully exhausted in September 2019. Beginning in October 2019, state funding will be used to support the Complete Eats program. What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?Department of Health (DOH) utilized a variety of communication tools and tactics to disseminate results to communities of interest. Two DOH webpages (www.doh.wa.gov/FINI and www.doh.wa.gov/CompleteEats) provide information about the FINI project and incentive programs to stakeholders, SNAP clients, and the general public. Fact sheets, data briefs, a progress report and other materials are available on the webpages. DOH staff presented about its FINI project at five conferences (three national, two state). Information was also provided to the Governor's Council for the Healthiest Next Generation initiative and throughout the Washington State Legislative session (January-March 2019), as it related to state funding for SNAP incentive programs. The FINI project was discussed at site visits hosted by Advisory Network members (DOH not involved). DOH published information about FINI programs through social media posts. DOH's FINI implementing partners and Advisory Network partners disseminated results statewide and local activities. For example, Northwest Harvest (an Advisory Network member) hosted FINI participant stories on their website in January 2019. This was an opportunity for participants to share their experience with FINI programs to decision-makers and peers. At the local level, Yakima Valley Farm Workers Clinics participated in two media appearances to promote the Complete Eats Rx program as their clinic services and programs. For more information, see also PRODUCTS and OTHER PRODUCTS. What do you plan to do during the next reporting period to accomplish the goals?FARMERS MARKET MATCH: Implementation changes and additions DOH anticipates regional leads will recruit at least 4 additional farmers markets to offer SNAP incentives in the next reporting period. Additional markets are anticipated in high-need areas like eastern, rural Washington. Outreach With an anticipated 90+ markets offering SNAP incentives during the next reporting period, DOH will work with Department of Social and Health Services (DSHS), the state agency that administers SNAP, to send direct mail about SNAP incentives at farmers markets to 26,000 SNAP households in target areas. Utilizing the breadth and reach of FINI Advisory Network partners, DOH will work with Northwest Harvest, Washington State Department of Agriculture, Washington State Farmers Market Association, and DSHS to promote farmers market SNAP incentives. Promotional materials will be made available at food banks and pantries, through SNAP outreach, and SNAP-Ed programs. Evaluation During the 2019 farmers market season, DOH will continue to offer an electronic SNAP customer survey. The survey will test knowledge, attitudes, and beliefs about the SNAP incentive and fruit/vegetable purchase and consumption. Analysis of responses will take place in November/December 2019. DOH FINI and DOH WIC FMNP programs analyze responses from the farmers market vendor survey. PRODUCE PRESCRIPTIONS: Implementation changes and additions DOH will continue to work with Safeway to make produce voucher redemption seamless for customers through store-level education of front end management teams. Health systems will continue to issue produce vouchers to SNAP clients in tandem with a variety of individual and group nutrition education and behavior change strategies (motivational interviewing, evidence-based chronic disease prevention programs). DOH expects federal grant funding for the Complete Eats Rx program to be fully exhausted by June 2019. If DOH receives state funding for FINI programs, the Complete Eats Rx program would continue uninterrupted through December 2019. Evaluation DOH plans to submit for peer-reviewed journal publication a process and preliminary outcome evaluation of the Complete Eats Rx program. DOH will continue to conduct market basket analyses using scanner data from transactions involving the produce prescriptions redeemed at grocery stores. DOH will continue to implement an online, patient/client-level survey to assess how the produce prescriptions impact recipients' consumption of fruits and vegetables and self-reported health. The survey is anticipated to be open until December 2019. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: Implementation DOH expects private funding for Complete Eats to be fully exhausted in September 2019. The program will continue to operate, albeit at a $3 (not $5) incentive beginning in October 2019. Safeway will alert 169 store directors and front end management teams that Complete Eats program is changing to a $3 (not $5) incentive in September 2019. Outreach Strategic email communication/listserv blasts about Complete Eats will reach thousands of service providers and SNAP clients throughout the state to alert them that the program will change to a $3 (not $5) incentive in September and October 2019. DOH Complete Eats website will be updated to alert SNAP customers that the program will change to a $3 (not $5) incentive beginning in October 2019. Evaluation DOH will submit an abstract for presentation at the American Public Health Association about the Catalina program and changes in SNAP shoppers fruit and vegetable purchases as a result of the program. DOH and Safeway will work with Catalina to conduct in-depth analysis of coupon redeemers market baskets.

Impacts
What was accomplished under these goals? OBJECTIVES #1, #2: FARMERS MARKET MATCH: Three incentive programs are supported by DOH's FINI grant: Fresh Bucks, Fresh Match, and Double Up Bucks. DOH uses a regional lead model to implement FINI activities and incentive in farmers markets across Washington. Catholic Charities of Spokane (CCS), Washington State University - Clark County Extension, MultiCare Health System, City of Seattle Office of Sustainability and Environment (OSE), Skagit Valley Farmers Market Coalition (SVFMC), and Kitsap Public Health District (KPHD), and Olympia Farmers Market manageincentives in their respective regions. During this reporting period (April 1, 2018- March 31, 2019), 92 markets in 21 counties offered SNAP incentives. Markets processed 30,503 SNAP transactions valued at $525,509 and redeemed $491,270 in SNAP incentives (SNAP transactions and incentives totaled $1,016,779). The estimated economic impact of these SNAP transactionsand incentives is $1,820,034, based on USDA's estimate that for every SNAP dollar spent, $1.79 is generated in the local economy. Markets served 12,332 unique SNAP customers and 2,850 repeat SNAP customers. During the reporting period DOH launched two farmers market-related surveys to measure the impact of Farmers Market Match programs on both participants and farmers market vendors. An online participant-level survey launched in June 2018 for SNAP clients who use Farmers Market Match. Eighty-five percent of respondents indicated they eat more fruits and vegetables as a result of the incentive program. An online farmers market vendor survey launched February 2019 and analysis is forthcoming. PRODUCE PRESCRIPTIONS:Three produce prescription models are supported by DOH's FINI grant: Fresh Bucks Rx, Complete Eats Rx, and Small Steps. 16 health systems prescribed fruits and vegetables to SNAP patients/clients. During the reporting period DOH implemented an online patient-level survey for SNAP clients who receive Rx vouchers. Ninety percent of respondents have indicated that they eat more fruits and vegetables as a result of the Rx program, and 84% said they are less likely to run out of food as a result of the Rx program. Fresh Bucks Rx - City of Seattle Office of Sustainability and Environment partnered with King County farmers markets and six ethnic grocery stores to offer Fresh Bucks Rx at 6 health systems. These six health systems issued $302,500 worth of produce vouchers; $87,170 (29%) were redeemed by 477 unique patients at 58 farmers markets and grocery stores. The local economic impact of these produce vouchers is estimated to be $156,034 based on the USDA multiplier mentioned above. Complete Eats Rx - DOH partnered with Safeway to offer Fruit and Vegetable Prescriptions ($10 vouchers) at 11 health systemsduring thereporting period.These health systems issued $462,080 worth of produce vouchers; $264,880 (57%) were redeemed by 5,926 unique club card holders at 154 grocery stores. Small Steps - UnitedHealthcare Community Plan (UHCCP) partnered with 47 Federally Qualified Health Centers and WIC clinics to offer $10 vouchers for a local farmers market where they can select fruits and vegetables.These farmers markets redeemed 2,791 vouchers, of which 1,413 (worth $14,130) were redeemed by SNAP participants. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: DOH and Safeway operated Complete Eats for SNAP shoppers who spend $10 on fruits and vegetables with their EBT andloyalty cardto receive a $5 coupons for fruits and vegetables.From April- June 2018 the program operated with federal funding; from July-November 2018 the program ceased operation; and from December 2018- March 2019 the program operated with private funding. When Complete Eats operated, DOH coordinated with dozens of community-based partners to distribute Complete Eats promotional materials. During this reporting period, 669,563 coupons were issued at participating stores; and 162,322 coupons were redeemed (24%) valued at $811,610. OBJECTIVES #3, #4: FARMERS MARKET MATCH: Regional leads targeted community outreach and education about incentives to organizations that serve SNAP populations. Many of theregional leadshave presented to staff at Community Service Offices, CSOs, (application office for SNAP benefits) about utilizing farmers market incentives. Lead organizations distributed linguistically-appropriate promotional materials to CSOs. Participating farmers markets implement many behavior change strategies, including culturally-relevant partnerships that address health and nutrition. For example, OSE worked with the Somali Health Board to conduct outreach at health clinics and through community based organizations in connection with a planned post-Ramadan nutrition class and the role of nutrition in reducing lead poisoning. PRODUCE PRESCRIPTIONS: Sixteen health systems issued produce prescriptions (cash-value vouchers) in tandem with individual and group nutrition education and behavior change strategies.Nisqually Tribal Health Department distributes vouchers through their medical clinic (via a public health nurse), as well as during nutrition education classes with the Tribe's dietitian. Verdant Health Commission (VHC) partnered with Homage Senior Services to issue vouchers in group nutrition demonstrations to senior adults who are food insecure. Health systems partnershave anecdotally reported that no-show rates have decreased for appointments in which the voucher is issued. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: DOH coordinated with dozens of statewide and local partners to promote the Complete Eats program, using flyers and recipe cards that detailed the incentive.SNAP-Ed local contractors throughout the state promoted the Complete Eats program as it connected with their nutrition education services. DOH partnered with the state WIC office to offer Complete Eats program materials to more than 200 local WIC offices throughout the state. SNAP-Ed and WIC participants are especially motivated to utilize skills learned in SNAP-Ed and WIC nutrition education classes when they have financial incentive to purchase healthy foods (via the produce coupon). OBJECTIVES #5: FARMERS MARKET MATCH: Five regional leads continued or started a SNAP Ambassador/peer-to-peer model for outreach and educations about SNAP incentives at farmers markets.OSE launched a Racial Equity Toolkit to inform Fresh Buck strategies, including program implementation and capacity. OSE posed questions to the community to engage participant feedback and ideas, which included conducting a focus group with 11 Somali women and a separate focus group with 10 farmers market managers. DOH worked with regional leads to distribute an onlineSNAP participant survey that evaluated the impact of Farmers Market Match for participants. PRODUCE PRESCRIPTIONS: Two health systemsoffered classes to "Stretch EBT Dollars"-- these classes help to empower SNAP participants that receive the Rx vouchers by creating an informal peer-to-peer network. Yakima Valley Farm Workers Clinics offered a program led by a registered dietitian for patients ages 8-14 who have a BMI greater than the 85th percentile and offered the Rx to eligible patients. DOH promoted an online survey to assess produce prescriptions impact on recipients' consumption of fruits and vegetables. Ninety-four percent of respondents indicated they eat more fruits and vegetables as a result of produce prescriptions. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: The Complete Eats program ran through June 2018, stopped from July-November 2018, and restarted in December 2018. While the program was in operation, SNAP-Ed local agencies, community-based organizations, and local health departments promoted Complete Eats to their program.During the first year of the Complete Eats program (Jun 2017-June 2018), Catalina reported that SNAP customers who used Complete Eats coupons spent 15% more on fruits and vegetables (vs. when the program wasn't operating).

Publications

  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Nambuthiri S, Marcinkevage J, Auvinen A. Washington State Farmers Market Incentive Programs Promote Purchase of Healthy, Local Food by SNAP Participants. Presentation at Council of State and Territorial Epidemiologists (CSTE) Annual Conference; 2018 June 10-14; West Palm Beach, FL.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Marcinkevage J, Nambuthiri S, Auvinen A. Fruit and Vegetable Prescriptions Improve Access to Healthy Foods Among Food Insecure IndividualsWashington State, 2016-17. Presentation at Council of State and Territorial Epidemiologists (CSTE) Annual Conference; 2018 June 10-14; West Palm Beach, FL.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Auvinen A, Marcinkevage J, Nambuthiri S. Public Health Implications of a Large-Scale Multi-Sector Produce Prescription Program. Panel session presented at American Public Health Association Annual Conference; 2018 November 13; San Diego, CA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Auvinen A. Washingtons Food Insecurity Nutrition Incentive (FINI) Grant. Presentation at Washington State Board of Health quarterly meeting; 2019 March 13; Tumwater, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Wells J, Auvinen A, Teske C. Charting the Course for Food Access Programs in 2019 and Beyond. Presentation at Washington State Farmers Market Conference; 2019 March 22; Walla Walla, WA.


Progress 04/01/17 to 03/31/18

Outputs
Target Audience:The primary target audience for this project are Washingtonians who participate in the Supplemental Nutrition Assistance Program (SNAP). By providing monthly benefits to eligible low-income individuals and families, SNAP plays a critical role in improving food and nutrition security and child and adult health. During the 2017 state fiscal year, 1,270,627 people accessed SNAP in Washington; 460,552 (36%) whom were children. Among all SNAP clients in Washington, 21% were Hispanic; 13% were Black/African American; 9% were Asian/Pacific Islander; 7% were American Indian/Alaska Native. Washington State Department of Health (DOH) and its FINI implementing partners are using three main strategies to offer incentives to SNAP participants so they can afford more fruits and vegetables. The target audience reached during this reporting period (April 1, 2017 - March 31, 2018) are summarized below, by incentive strategy. FARMERS MARKET MATCH: Seventy-nine (79) farmers markets in 18 counties offered SNAP incentive programs. SNAP incentive programs are available in densely-populated metropolitan areas (i.e. City of Seattle), as well as rural cities and counties in central, eastern, and western WA. Participating markets served 9,779 unique SNAP customers and 3,784 repeat SNAP customers during the reporting period. PRODUCE PRESCRIPTIONS: Three produce prescription models are supported by DOH's FINI project: Fresh Bucks Rx, Complete Eats Rx, and Small Steps. Fresh Bucks Rx is run by City of Seattle Office of Sustainability and Environment working with King County farmers markets, six ethnic retail stores, and five Seattle-based health systems that serve racially/ethnically diverse patient populations with a high percentage of Medicaid and uninsured patients. The target audience is SNAP patients who screen positive for food insecurity. Some clinics are also screening for nutrition-related chronic disease as a criteria for produce prescription eligibility. Fresh Bucks Rx served 1,046 unique patients or families during the reporting period. Complete Eats Rx is run by DOH working with Albertsons Co. (DBA Safeway) and 8 health systems. The target population is SNAP clients in participating clinics or home visiting programs, chronic disease prevention and management programs, and SNAP-Ed classes or events. Complete Eats Rx served 1,392 SNAP clients during the reporting period (excludes clients who are not Loyalty Club Card holders). Small Steps is a program run by UnitedHealthcare Community Plan. The target audience is SNAP clients who are also Medicaid eligible/Medicaid-Medicare eligible low-income seniors. Small Steps served 1,248 SNAP clients during the report year. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: 169 large-chain (Safeway) grocery stores in 30 counties offered the SNAP incentive program Complete Eats. The program is run by Safeway and targets SNAP shoppers who use their EBT and Loyalty Club Card to purchase fruits and vegetables. Participating grocery stores served 69,117 unique SNAP customers and 28,150 repeat SNAP customers during the reporting period. Changes/Problems:Funding for Complete Eats is expected to be fully exhausted some time in 2018. Due to high demand and usage by SNAP customers, the program will end after 12 months (instead of the originally slated 24 months). What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?Department of Health (DOH) utilized a variety of communication tools and tactics to disseminate results to communities of interest. Two DOH webpages (www.doh.wa.gov/FINI and www.doh.wa.gov/CompleteEats) provide information about the FINI project and incentive programs to stakeholders, SNAP clients, and the general public. Fact sheets, data briefs, a progress report and other materials are available on the webpages. DOH staff presented about its FINI project at two conferences (two national, two state) and on one national webinar. Information was also provided to the Governor's Council for the Healthiest Next Generation initiative and the Community Health Advisory Committee (a council made up of local health department leadership). The FINI project was discussed at three Congressional site visits. DOH worked with Northwest Harvest to publish a newsletter about the FINI project and WA State Department of Agriculture to publish social media posts. DOH's FINI implementing partners disseminate results of their regional activities. For example, Spokane Regional Health District coordinated a press event for the Complete Eats program, and received attention from at least five local media outlets. For more information, see also PRODUCTS and OTHER PRODUCTS. What do you plan to do during the next reporting period to accomplish the goals?FARMERS MARKET MATCH: Implementation changes and additions: DOH anticipates regional leads will recruit at least 7 additional farmers markets to offer SNAP incentives in the next reporting period. Additional markets are anticipated in high-need areas like Snohomish County (one of only four counties in Washington that has more than 100,000 SNAP recipients). Outreach With an anticipated 90+ markets offering SNAP incentives during the next reporting period, DOH will work with Department of Social and Health Services (DSHS), the state agency that administers SNAP, to send direct mail about SNAP incentives at farmers markets to 130,000 SNAP households in target areas. Utilizing the breadth and reach of FINI Advisory Network partners, DOH will work with Northwest Harvest, Washington State Department of Agriculture, Washington State Farmers Market Association, and DSHS to promote farmers market SNAP incentives. Promotional materials will be made available at food banks and pantries, summer meal sites, child care programs, and through SNAP outreach and SNAP-Ed programs. Evaluation In 2018,DOH plans to launch an electronic SNAP customer survey. The survey will mirror the Produce Prescription patient survey, and test knowledge, attitudes, and beliefs about the SNAP incentive and fruit/vegetable purchase and consumption. DOH plans to gather farmers market feedback cards from SNAP customers (similar to 2017); feedback cards will be used for program improvement. UW Center for Public Health Nutrition (CPHN) will develop and disseminate a market manager survey to gauge sustainability and future planning for FINI markets. DOH and UW Center for Public Health Nutrition will also begin developing more in-depth participant-level evaluation Measures (via phone interviews or focus groups). PRODUCE PRESCRIPTIONS: Implementation changes and additions DOH will continue to work with Safeway to make produce voucher redemption seamless for customers through store-level education of front end management teams. Health systems will continue to issue produce vouchers to SNAP clients in tandem with a variety of individual and group nutrition education and behavior change strategies (motivational interviewing, evidence-based chronic disease prevention programs). DOH, City of Seattle Office of Sustainability and Environment, and UnitedHealthcare Community Plan will add at least 2 new healthcare partners into the produce prescription programs. Evaluation DOH will continue to implement an online, patient/client-level survey to assess how the produce prescriptions impact recipients' consumption of fruits and vegetables and self-reported health. The survey is anticipated to be open until December 2019. DOH will continue to conduct market basket analyses using scanner data from transactions involving the produce prescriptions redeemed at grocery stores. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: Implementation DOH expects grant funding for Complete Eats to be fully exhausted in 2018 due to high demand and usage by SNAP customers. The program was originally slated to operate through May 2019. DOH and Safeway will alert customers and community partners in advance of the program ending. Safeway will alert 169 store directors and front end management teams that Complete Eats program is ending (depending on when FINI funds are exhausted). Outreach Strategic email communication/listserv blasts about Complete Eats will reach thousands of service providers and SNAP clients throughout the state to alert them that the program will end in 2018. DOH Complete Eats website will be updated to alert SNAP customers that the program will end. Evaluation: DOH and Safeway will work with Catalina to conduct in-depth analysis of coupon redeemers market baskets.

Impacts
What was accomplished under these goals? OBJECTIVES #1, #2: FARMERS MARKET MATCH: Betweent April 1, 2017- March 31, 201, 79 markets in 18 counties offered SNAP incentive programs. This is an increase from the first year of FINI (2015-16), when only 48 markets participated. Markets processed 24,308 SNAP transactions valued at $400,623 and redeemed $271,215 in SNAP incentives (SNAP transactions and incentives totaled $671,838). The estimated economic impact of these SNAP transactions and fruit and vegetable incentives is $1,202,589, based on USDA's estimate that for every SNAP dollar spent, $1.79 is generated in the local economy. The redemption rate for incentives was 96%. Participating markets served 9,779 unique SNAP customers and 3,784 repeat SNAP customers during the reporting period. DOH and the Department of Social and Health Services (SNAP administrator) coordinated direct mailings to SNAP households encouraging clients to visit participating markets. PRODUCE PRESCRIPTIONS:15 health systems prescribed fruits and vegetables to SNAP patients/clients. The prescription is a paper voucher that recipients can use like cash to buy produce at participating farmers markets and grocery stores. Several sites also incorporated food insecurity screening and nutrition wraparound services (referrals to SNAP eligibility and enrollment providers, community food resources) into their institutional workflows. Safeway educated front end teams in 169 stores about how to process the Complete Eats Rx vouchers. OSE educated 32 farmers market managers and 6 retail stores on how to redeem Fresh Bucks Rx. In September 2017,DOH launched an online patient-level survey for SNAP clients who receive Rx vouchers. Fresh Bucks Rx- City of Seattle Office of Sustainability and Environment partnered with King County farmers markets, six ethnic grocery stores, and 5 health systemsto offer Fresh Bucks Rx. These five health systems issued $102,740 worth of produce vouchers; $81,048 (79%) were redeemed by 1,046 unique patients at 32 farmers markets and grocery stores. The local economic impact of these produce vouchers is estimated to be $145,076 based on the USDA multiplier mentioned above. Complete Eats Rx- Nine participating health systems issued $151,780 worth of produce vouchers; $74,410 (49%) were redeemed by 1,392 unique club card holders at 107 grocery stores.Two additional health systems started issuing the Rx, Sea Mar Community Health Centers and Verdant Health Commission. Small Step - UnitedHealthcare Community Plan (UHCCP) partnered with 67 Federally Qualified Health Centers and WIC clinics to offer $10 vouchers for a local farmers market where they can select fruits and vegetables. These sites issued 23,810 vouchers; 2,381 (10%) were redeemed, of which 1,248 were redeemed by SNAP participants. This lower redemption rate is likely due to the nature of the program, which requires participants to redeem vouchers at set locations and on specific days/times when UHCCP operates a booth at the farmers market. The local economic impact of the produce vouchers redeemed by SNAP clients alone is estimated to be $22,339 based on the USDA multiplier mentioned above. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: DOH and Safeway launched Complete Eats in June 2017. SNAP shoppers who spend $10 on fruits and vegetables with their EBT and Loyalty Club Card receive a $5 coupons for fruits and vegetables. The program rolled out in 152 stores in June, and another 17 stores located in Southwest Washington (operated by a different Safeway Division) in September. 169 grocery stores in 30 counties offered SNAP incentive programs. 838,384 coupons were issued at participating stores; and 167,235 coupons were redeemed (20%) valued at $836,175. Grocery stores served 69,117 unique SNAP customers and 28,150 repeat SNAP customers during the reporting period. OBJECTIVES #3, #4: FARMERS MARKET MATCH: Regional leads targeted community outreach and education about farmers market incentives (including SNAP and WIC/Senior FMNP) to a variety of organizations that serve SNAP populations. For example, SVFMC presented at the Within Reach Basic Food Education Forum to educate SNAP outreach specialists about the Double up Bucks program. 25 bus advertisements were used by SVFMC to promote the Double Up Bucks program in Skagit County. Participating farmers markets implement many behavior change strategies, including culturally-relevant cooking demonstrations, sampling, and market tours. KPHD implemented a Healthy Kids program at their markets, aimed at educating children about healthy lifestyles and eating habits. PRODUCE PRESCRIPTIONS: Fifteen health systems issued produce prescriptions (cash-value vouchers) in tandem with a variety of individual and group nutrition education and behavior change strategies. As part of a SNAP-Ed Health Outcomes Project for prenatal and postpartum women, dietitians at Yakima Neighborhood Health Services, Moses Lake Community Health Center, Wahluke Clinic, and MultiCare Health System issue vouchers to SNAP clients. At Virginia Mason Memorial Hospital vouchers distribution is directly connected to participation in behavior change classes like Diabetes Management and Diabetes Prevention Program. Community Health Workers serving the Seattle Housing Authority led walking and gardening groups, and youth-focused nutrition classes, and utilized produce prescriptions in those activities. Verdant Health Commission (VHC) partnered with Homage Senior Services to issue vouchers in group nutrition demonstrations to senior adults who are food insecure. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY:More than100 statewide and local partnerspromoted the Complete Eats program, using flyers and recipe cards that detailed the incentive. Nearly 50 CSOs (application office for SNAP benefits) provided promotional materials and information to SNAP clients. Likewise, DOH partnered with WIN 211 (phone and web resource center for social services) to include information about Complete Eats on the website and as a call center message. At least 18 SNAP-Ed agencies promoted the Complete Eats program to their SNAP clients during the reporting period. SNAP-Ed participants are especially motivated to utilize skills learned in SNAP-Ed nutrition education classes when they have financial incentive to purchase healthy foods (via the produce coupon). OBJECTIVES #5: FARMERS MARKET MATCH: Two regional leads continued a SNAP Ambassador/peer-to-peer model for outreach and educations about SNAP incentives at farmers markets. OSE maintained an online"Outreach Map"to plot outreach activitiesand direct outreach strategies. PRODUCE PRESCRIPTIONS:VHC partnered with organizations serving youth and/or seniors in Snohomish County to implement the produce prescription program, including: Edmonds School District and their school-based family advocates; Homage Senior Services Nutrition Program; residence coordinators at SHAG Senior Housing Properties. Spokane Regional Health District continued to leverage their Community Health Advocate (CHA) program to implement the produce prescription vouchers redeemable at Safeway. The CHA program is a peer-to-peer health promotion program that operates in affordable housing properties managed by the Spokane Housing Authority. Virginia Mason Memorial Hospital partnered with a Yakima local elementary school to offer a Chronic Disease Self-Management Program.DOH coordinated with health systems to promote an online survey to assess how produce prescriptions impact recipients' consumption of fruits and vegetables and self-reported health. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: The Complete Eats program launched in June 2017. Community-based organizations and local SNAP-Ed agencies promoted the program to their SNAP clients. SNAP-Ed agencies and FINI partners provided Safeway cashiers technical assistance to implement the program in store.

Publications

  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Nambuthiri S, Marcinkevage J, Igoe B. Washington State Food Insecurity Nutrition Incentives (FINI ) Initiative: Year 1 Update. Poster session at Council of State and Territorial Epidemiologists (CSTE) Annual Conference; 2017 June 4-8; Boise, ID.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Tong Morrow K. Washington States FINI Project. Panel session at Association of SNAP Nutrition Education Administrators (ASNNA) Conference; 2018 Feb. 8; Arlington, VA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Auvinen A and Wells J. Washingtons FINI Grant. Presentation at Washington State SNAP-Ed Forum; 2018 March 28; Seattle, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Auvinen A and Jacobson M. Fruit and Vegetable Rx: A Nexus for Health Care, Public Health and the Food System. Presentation at the Washington State Public Health Association Conference; 2018 October 17; Wenatchee, WA.
  • Type: Other Status: Published Year Published: 2018 Citation: Washington States FINI Grant Progress Report. Available online: www.doh.wa.gov/FINI. March 2018.


Progress 04/01/16 to 03/31/17

Outputs
Target Audience:The primary target audience for this project are Washingtonians who participate in the Supplemental Nutrition Assistance Program (SNAP). By providing monthly benefits to eligible low-income individuals and families, SNAP plays a critical role in improving food and nutrition security and child and adult health. During the 2016 state fiscal year, an average of 561,095 households and 1,007,629 people accessed SNAP each month in Washington. The average number of children who accessed SNAP in Washington per month was 369,889. Washington State Department of Health (DOH) and its FINI implementing partners are using three main strategies to offer incentives to SNAP participants so they can afford more fruits and vegetables. The target audience reached during this reporting period (April 1, 2016 - March 31, 2017) are summarized below, by incentive strategy. FARMERS MARKET MATCH Seventy-three (73) farmers markets in 18 counties offered SNAP incentive programs. SNAP incentive programs are available in densely-populated metropolitan areas (i.e. City of Seattle), as well as rural cities and counties in central, eastern, and western WA. Participating markets served 9,819 unique SNAP customers and 4,267 repeat SNAP customers during the reporting period (excludes approximately 1,000 paper-based transaction which do not enable tracking of unique and repeat customers). PRODUCE PRESCRIPTIONS Three produce prescription models are supported by DOH's FINI project: Fresh Bucks Rx, Complete Eats Rx, and Small Steps. Fresh Bucks Rx is run by City of Seattle Office of Sustainability and Environment working with King County farmers markets and two Seattle-based health systems that serve racially/ethnically diverse patient populations with a high percentage of Medicaid and uninsured patients. The target audience is SNAP patients who screen positive for food insecurity. Some clinics are also screening for nutrition-related chronic disease as a criteria for produce prescription eligibility. Fresh Bucks Rx served 88 unique patients or families during the reporting period. Complete Eats Rx is run by DOH working with Albertsons Co. (DBA Safeway) and 8 health systems. The target population is SNAP clients in participating clinics or home visiting programs, chronic disease prevention and management programs, and SNAP-Ed classes or events. Complete Eats Rx served 1,381 SNAP clients during the reporting period (excludes clients who are not Loyalty Club Card holders). Small Steps is a program run by UnitedHealthcare Community Plan. The target audience is SNAP clients who are also Medicaid eligible/Medicaid-Medicare eligible low-income seniors. Small Steps served 1,551 SNAP clients during the report year. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY Nothing to report. Complete Eats was not implemented during this reporting period. Changes/Problems:Spending lags slightly due to delayed funding in 2015 and subsequently late startup of incentive programs. However, the rate of expenditure has increased since the first year and is expected to increase significantly by July 2017, when all three incentive programs will be in operation. After examining different Catalina coupon redemption rates for different offer types, DOH and Safeway will launch Complete Eats by offering a $5 off coupon rather than a $3 off coupon. What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?DOH utilized a variety of communication tools and tactics to disseminate results to communities of interest. Two DOH webpages (www.doh.wa.gov/FINI and www.doh.wa.gov/CompleteEats) provide information about the FINI project and incentive programs to stakeholders, SNAP clients, and the general public. Fact sheets, data briefs and other materials are available on the webpages. DOH worked with Nursing Commission News and Northwest Harvest to publish newsletters about the FINI project. DOH staff presented about its FINI project at five conferences (three national, one state, one local) and on four webinars (two national, two state). Four farmers markets hosted Congressional representatives and staff from Senator Patty Murray's office to showcase the incentive programs and educate decision makers about the FINI project. Talking points, PowerPoint presentations, fact sheets and updates were provided to the Advisory Network so representatives could educate their agency leadership. Information was also provided to the Washington Food Systems Roundtable and the Governor's Council for the Healthiest Next Generation initiative. Similarly, DOH's FINI implementing partners disseminate results of their regional and local activities. For example, City of Seattle Office of Sustainability and Environment issued news releases when its Fresh Bucks Rx program launched, prompting several local television stations to run stories in the evening news programs. For more information, see also PRODUCTS and OTHER PRODUCTS. What do you plan to do during the next reporting period to accomplish the goals?FARMERS MARKET MATCH: Implementation changes and additions DOH anticipates regional leads will recruit at least 8 additional farmers markets to offer SNAP incentives in the next reporting period. Additional markets are anticipated in high-need areas like Yakima County (25% of residents in Yakima County are SNAP recipients vs. 15% of residents in Washington). During the 2017 farmers market season, all markets will utilize Device Magic for SNAP transaction data collection. Outreach With an anticipated 80+ markets offering SNAP incentives during the next reporting period, DOH will work with Department of Social and Health Services (DSHS), the state agency that administers SNAP, to send direct mail about SNAP incentives at farmers markets to 110,000 SNAP households in target areas. Utilizing the breadth and reach of FINI Advisory Network partners, DOH will work with Northwest Harvest, Washington State Department of Agriculture, Washington State Farmers Market Association, Washington State Alliance of YMCAs, and DSHS to promote farmers market SNAP incentives. Promotional materials will be made available at food banks and pantries, summer meal sites, child care programs, and through SNAP outreach and SNAP-Ed programs. Evaluation During 2017 farmers market season, DOH will work with markets to distribute SNAP customer comment postcards to gather feedback on their experiences using the farmers market match programs. Customers will be able to mail their completed postcards to DOH with pre-paid return postage. DOH and FINI Advisory Network partners will use the postcards to share the personal and tangible impacts SNAP incentives have on customers. Graduate students at University of Washington will collect and analyze the postcards and share results with DOH. PRODUCE PRESCRIPTIONS: Implementation DOH will continue to work with Safeway to make produce voucher redemption seamless for customers through store-level education of front end management teams. Health systems will continue to issue produce vouchers to SNAP clients in tandem with a variety of individual and group nutrition education and behavior change strategies (motivational interviewing, evidence-based chronic disease prevention programs). DOH, City of Seattle Office of Sustainability and Environment, and UnitedHealthcare Community Plan anticipateadding clinic sites into the produce prescription programs. Evaluation DOH will continue to design and pilot test an online, patient/client-level survey to assess how the produce prescriptions impact recipients' consumption of fruits and vegetables and self-reported health. The survey is anticipated to open in July 2017. DOH will continue to fine tune processes and reports for transaction data related to produce prescriptions. DOH staff will start to conduct market basket analyses using scanner data from transactions involving the produce prescriptions redeemed at grocery stores. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: Implementation DOH is working with Safeway to launch Complete Eats by end of June 2017. Safeway will design the coupon art and work with Catalina to set up the system so that coupons are triggered to print when SNAP customers make a minimum purchase of $10 of fruits and vegetables using their SNAP benefits. Safeway will train 150 stores directors and front end management teams on the Complete Eats program and coupon offer. Safeway will issue a merchandising memo and send 1,000 shelf tags to 150 stores. Store retail integrity teams will place shelf tags near qualifying canned and frozen products (i.e. products with no added fats, sugar or salt). Outreach DOH will work with Safeway to host a Complete Eats launch event. Safeway will develop and produce a public service announcement. DOH will design print and social media that partners can use in outreach to SNAP clients. DOH will partner with FINI Advisory Network members, statewide non-profits, SNAP-Ed providers, and dozens of community-based organizations to promote Complete Eats via print and social media in food banks, community health clinics, and other service organizations/programs. Strategic email communication/listserv blasts about Complete Eats will reach thousands of service providers throughout the state. Promotional material will be made available to all local WIC agencies and all Community Service Offices (application office for SNAP benefits) throughout the state. Information about Complete Eats will be posted on WIN211, an online database of community resources that receives hundreds of thousands searches for food resources each year. Evaluation DOH and Safeway will continue to fine tune processes and reports for transaction data related to Complete Eats incentives. DOH staff will start to use incentive transaction data to conduct market basket analysis.

Impacts
What was accomplished under these goals? OBJECTIVES #1, #2: FARMERS MARKET MATCH: Between April 1, 2016 and March 31, 2017), 73 markets in 18 counties offered SNAP incentive programs. This is an increase from 2015-16, when only 48 markets participated. Markets processed 26,865 SNAP transactions valued at $344,469 and redeemed $247,045 in SNAP incentives. The estimated economic impact of these SNAP transactions and fruit and vegetable incentives is $1,058,810, based on USDA's estimate that for every SNAP dollar spent, $1.79 is generated in the local economy. The incentives redemption rate was 96%. Participating markets served 9,819 unique SNAP customers and 4,267 repeat SNAP customers during the reporting period (excludes approximately 1,000 paper-based transaction which do not enable tracking of unique and repeat customers). PRODUCE PRESCRIPTIONS: In July 2016, three produce prescription models were launched at 11 health systems. The health systems partners designed and implemented processes to screen for SNAP participation and issue the produce vouchers during a variety of patient/client encounters (see also TARGET AUDIENCE). Several sites also incorporated food insecurity screening and nutrition wraparound services (referrals to SNAP eligibility and enrollment providers, community food resources) into their institutional workflows. On the redemption side, participating farmers markets and grocery stores developed systems to verify SNAP participation at the point-of-sale and track redemption of produce vouchers. Safeway educated front end teams in 150 stores about how to process the vouchers to make redemption seamless for customers and so the data associated with voucher redemption is accurate as possible (using the correct PLU assigned to each health system site). Similarly, City of Seattle Office of Sustainability and Environment educated 28 farmers market managers on how to redeem Fresh Bucks Rx. DOH developed processes and systems to collect quarterly distribution and redemption data from participating health systems, farmers markets and Safeway. Key results from the reporting period (April 1, 2016 - March 31, 2017) are described below. Fresh Bucks Rx - Two participating health systems issued $20,640 worth of produce vouchers; $13,420 (65%) were redeemed by 88 unique patients at 15 farmers markets. The local economic impact of these produce vouchers is estimated to be $24,022 based on the USDA multiplier mentioned above. Complete Eats Rx - Seven participating health systems issued $62,860 worth of produce vouchers; $43,810 (70%) were redeemed by 1,381 unique club card holders at 86 Safeway stores. Small Steps - UnitedHealthcare Community Plan (UHCCP) partnered with 59 clinics to offer $10 vouchers for a local farmers market. Clinics issued 22,450 vouchers; 2,706 (12%) were redeemed, of which 1,551 were redeemed by SNAP participants. This lower redemption rate is likely due to the nature of the program, which requires participants to redeem vouchers at set locations and on specific days/times when UHCCP operates a booth at the farmers market. The local economic impact of the produce vouchers redeemed by SNAP clients alone is estimated to be $27,763 based on the USDA multiplier mentioned above. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: DOH and Safeway worked on plans to execute Complete Eats by June 2017. Throughout the year, key personnel from DOH and Safeway met to examine historical SNAP transaction and coupon redemption data in order to design and optimize an incentive using Catalina coupons. OBJECTIVES #3, #4: FARMERS MARKET MATCH: Regional leads targeted community outreach and education about farmers market incentives (including SNAP and WIC/Senior FMNP) to a variety of organizations that serve SNAP populations. For example, Catholic Charities of Spokane partnered with social service agencies to distribute over 50,000 fliers and promotional materials throughout eastern WA. Skagit Valley Farmers Market Coalition presented to Community Service Offices (application office for SNAP benefits) staff about utilizing Double Up Bucks and distributed English and translated materials to the offices. Behavior change strategies at farmers markets were plentiful. Farmers markets and partner organizations provided culturally relevant cooking demonstrations, sampling, market tours, and fruit/vegetable preparation and storage demonstrations to attract and engage SNAP participants. Five farmers markets in the City of Spokane implemented child- and parent-focused activities that engaged 30-100 children/households per week. Seattle's Neighborhood Farmers Market Alliance created videos for social media about preparing budget-wise meals using farmers market produce As part of farmers market field trips, Skagit Valley Farmers Market Coalition distributed 150 bus passes to low-income community members who lack reliable transportation. PRODUCE PRESCRIPTIONS: Eleven health systems issued produce prescriptions in tandem with a variety of individual and group nutrition education and behavior change strategies. SNAP-Ed providers issued vouchers to SNAP clients during interactive nutrition and physical activity classes for prenatal and postpartum women. Dietitians issued vouchers during clinic appointments in which motivational interviewing techniques were used to engage patients in discussions about healthy food choices.SRHD CHA program led educational grocery store tours for voucher recipients. Nutritionists at Yakima Valley Memorial Hospital issued vouchers to SNAP clients through their chronic disease prevention and management programs. Aligning the produce prescriptions with client education and counseling adds value to both the FINI project and participating health systems. Health systems partners reported the voucher is a useful tool to engage patients/clients in educational and counseling sessions since it provides economic support that helps patients achieve healthy eating goals. SNAP-Ed providers consistently reported higher retention in classes where the voucher is made available to SNAP clients. Meanwhile, the complementary education and counseling motivates clients to use their produce vouchers and buy more fruits and vegetables. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: Complete Eats was not implemented during the reporting period. OBJECTIVE #5: FARMERS MARKET MATCH: Two regional leads used and expanded a SNAP Ambassador/peer-to-peer model for outreach and education about incentives at farmers markets. For example, City of Seattle partnered with four community-based organizations (CBOs) serving racially/ethnically diverse (e.g. Latino, Somali) communities to encourage use of SNAP farmers market incentives. CBOs and farmers markets offered culturally relevant cooking demonstrations and farmers market tours for SNAP participants unfamiliar with farmers markets. PRODUCE PRESCRIPTIONS: SRHD leveraged their CHA program to pilot test the produce prescription vouchers redeemable at Safeway. The CHA program is a peer-to-peer health promotion program that operates in affordable housing properties managed by the Spokane Housing Authority. The CHAs are residents of SHA properties and are charged with engaging and educating their fellow residents in health-related outreach. The CHAs administered a customer service survey to help identify barriers or improvement needs in the voucher redemption process. Safeway and DOH used the information to provide additional training and tools for store front end management teams about the produce prescription program. With input from health system partners, DOH worked on the development of an online survey to assess how the produce prescriptions impact recipients' consumption of fruits and vegetables and self-reported health. COMPLETE EATS - PRODUCE COUPONS AT SAFEWAY: Program design completed and data collection determined, to allow for a June 2017 launch.

Publications

  • Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Marcinkevage J, Nambuthiri S, Igoe B. Washington States Large-scale FINI Project. Panel session presented at American Public Health Association Annual Conference; 2016 Oct. 29  Nov. 2; Denver, CO.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Auvinen A. Washington States Food Insecurity Nutrition Incentive (FINI) Grant. Panel session presented at Seattle Childrens Hunger Symposium.; 2016 Dec. 3; Seattle, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Wells J. Washington States Food Insecurity Nutrition Incentive (FINI) Grant. Panel session presented at Seattle Childrens Hunger Symposium; 2017 Feb. 2; Blaine, WA.
  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Flores K and Igoe B. Synergies between Washington States Food Insecurity Nutrition Incentive Project & WIC Farmers Market Nutrition Program. Oral presentation at the National Association of Farmers Market Nutrition Program Annual Conference; 2016 Sept. 9; Juneau, AK.
  • Type: Journal Articles Status: Published Year Published: 2016 Citation: Igoe B, McDermot D, Stahre M. Strengthening the Connection Between the Supplemental Nutrition Assistance Program and Farmers Markets. Prev Chronic Dis 2016;13:160186. DOI: http://dx.doi.org/10.5888/pcd13.160186.
  • Type: Other Status: Published Year Published: 2016 Citation: NEWSLETTER - Igoe B. Washington Healthcare Providers are Now Prescribing Fruits and Vegetables. Washington Nursing Commission News. Summer 2016; Volume 10; Edition 25.
  • Type: Websites Status: Published Year Published: 2016 Citation: Washington State Department of Health. Food Insecurity Nutrition Incentive (FINI) Grant. Webpage. www.doh.wa.gov/FINI
  • Type: Websites Status: Published Year Published: 2016 Citation: Washington State Department of Health. SNAP Incentives. Webpage. www.doh.wa.gov/CompleteEats


Progress 04/01/15 to 03/31/16

Outputs
Target Audience:The primary target audience for this project is SNAP participants. Washington State Department of Health and its FINI grant subrecipients are using three main strategies to reach SNAP participants in order to offer them cash-value incentives to buy more fruits and vegetables. The target audiences reached by Washington State's FINI efforts are summarized below, by each of the three incentive strategies. 1. FARMERS MARKETS MATCHING INCENTIVES & DISCOUNTED COMMUNITY-SUPPORT AGRICULTURE (CSA) Forty-eight (48) farmers markets across nine counties offered matching fruit and vegetable incentives to SNAP participants at the point-of-sale. Of the 48 participating farmers markets, 20 are located in census tracts where the percentage of SNAP households is greater than 20 percent. Additionally, one CSA program offered subsidized Good Food Bags ($5 for a bag of produce worth $10) to SNAP participants. Bags could either be picked up at the Produce Food and Farm Hub warehouse or were distributed via a network of community partner organizations (e.g. public housing and child care sites). 2. FRUIT AND VEGETABLE PRESCRIPTIONS Thirty-seven (37) different healthcare sites (26 clinics and 11 WIC offices) in four counties issued fruit and vegetable prescriptions ($10 vouchers) to SNAP participants during one-on-one clinic appointments. Prescriptions could be redeemed at local farmers markets. SNAP participants who received the prescriptions in 2015 are also Medicaid eligible or Medicaid-Medicare eligible low-income seniors. 3. SUPERMARKET REBATE (CATALINA COUPON) Due to a delay in federalfunding, there is nothing to report this period. Changes/Problems:During the first year of FINI, DOH encountered the following problems: EXTREME DELAY IN FEDERAL FUNDING - Although the period of performance for this grant began on April 1, 2015, NIFA's administrative and fiscal review lasted four months, and it took an additional three months for the federal funds to appear in DOH's ASAP account. DOH records show that NIFA approved the release of DOH funds on August 26, 2015, but the federal funds were not transferred into DOH's ASAP account until December 15, 2015. This delay in funding significantly affected DOH's ability to execute contracts with 11 subrecipients and to hire key staff (e.g. a research investigator who will manage the data collection efforts across hundreds of outlets participating in FINI). As a result, the delay in funding impacted the sale of programming and incentive distribution in 2015. Furthermore, the delay in funding strained the relationships and partnerships DOH has with its subrecipients and key implementing partners. OVERDUE COMMUNICATIONS FROM USDA - On February 25, 2016 (nearly 11 months after the period of performance began), FNS unexpectedly emailed a memo to all FINI grantees that contained crucial details about the grant and incentive requirements. Some of these details affected the implementation of DOH's fruit and vegetable prescription programs. It would have been preferred to have such programmatic requirements detailed well in advance of the grant implementation, such as in the Request for Proposals. USDA DENIAL OF STATE AGENCY DATA SHARING - In January 2016, FNS denied a request from the Washington State Department of Social and Health Services (DSHS) to share farmers market EBT transaction data directly with the Washington State Department the Health (DOH), even with written approval from each farmers market outlet. In Washington State, DSHS is the SNAP administrator and DOH is a SNAP-Ed provider and the WIC administrator for the state. The purpose of this data sharing would have been to support the DOH's FINI evaluation and to ease some of the data collection burden on the farmers markets. The FNS Western Regional Office of FNS supported DOH's data sharing request, but FNS Headquarters denied the request on the basis that DOH is a FINI grantee. FNS's decision to deny farmers market EBT transaction data sharing between two state agencies that administer FNS programs seems counter-productive to NIFA's and DOH's goal to rigorously evaluate FINI activities. What opportunities for training and professional development has the project provided?DOH staff collaborated with UW School of Public Health faculty and 15 UW graduate students on a 10-week project to assess the cost, quality and availability of winter produce in FINI and non-FINI participating farmers market and grocery stores in Seattle, WA. The students completed a literature review to assess current state of knowledge about factors related to food purchasing decisions of SNAP participants. Subsequently, students developed a survey tool and protocol for use in supermarkets and farmers markets to assess fruit and vegetable cost, availability, variety, quality, origin, and retailer accommodations (e.g. hours of operation, parking, proximity to public transportation routes). The tool was implemented in a total four farmers markets and eight grocery stores. Students presented their results to FINI stakeholders on March 15, 2015. The survey results and lessons learned will be used to inform future SNAP incentive programming and for future assessments of produce cost, quality and availability in different seasons and geographic locations. Additionally, DOH staff and UW School of Public Health faculty are discussing opportunities for graduate-level students to work on FINI data collection and evaluation efforts as part of their PhD dissertation projects and master's thesis projects. Specifically, two master-level students and one PhD candidate are in the process of developing project proposals based on FINI activities. These projects will provide training and professional development opportunities for these students, but are also expected to enable deeper dive evaluations of specific FINI program sites. How have the results been disseminated to communities of interest?DOH recently finished compiling and summarizing program results from April 1 to December 31, 2015, so results have yet to be disseminated. DOH plans to disseminate program results to the following audiences: The FINI Advisory Network, a cross-sector network which includes representatives from state and local government agencies, farmers markets, grocery stores, healthcare systems, public health foundations, universities, and community-based organizations in Washington State. The Advisory Network includes the Department of Social and Health Services (state agency that administers SNAP in Washington) and a number of community-based organizations that serve SNAP participants. FINI subrecipients, who in turn will disseminate the results to their local communities of interest Governor Jay Inslee's Healthiest Next Generation Initiative staff The Washington State Food Systems Roundtable City of Seattle's Local Food Action Initiative Seattle Mayor Ed Murray The DOH's Community Health Advisory Committee, a broad cross-section of public health stakeholders, including academia, business, community-based organizations, emergency services, local government, health departments, medicine, social marketing, consumers and other sectors of the public health community. What do you plan to do during the next reporting period to accomplish the goals?There are no changes in DOH's NIFA-approved application or budgets. However, in order to mitigate the impact the delay in federal funding had on grant implementation, DOH is executing expedited, after-the-fact contracts with FINI subrecipients; 9 out of 11 contracts have been executed since December 15, 2015. DOH made a concerted effort to use 2015 for planning and preparations to enable full-scale implementation in 2016. In 2015, DOH and some subrecipients operated with their matching funds alone, which affected the scale of programming and extent of incentive distribution. Consequently, in 2016 DOH will be closely tracking the federal and non-federal budgets to expenditures catch up.

Impacts
What was accomplished under these goals? IMPACT With support from the FINI grant, Washington State Department of Health (DOH)and dozens of partners statewide have made it a priority to expand healthy food access and affordability for low-income individuals and families. The FINI grant supports cash-value incentives for participants inSNAP to buy fruits and vegetables at participating farmers markets and supermarkets. DOHis using three main strategies to distribute fruit and vegetable incentives to SNAP participants, thus making it easier for them to afford more fruits and vegetables: Farmers markets are matching purchases made with SNAPso shoppers can buy more fresh fruits and vegetables. Safeway supermarkets will offer rebates and discounts at the checkout on a large variety of fruits and vegetables (fresh, canned, and frozen with no added fats, sugar or salt). Health providers and community health workers will write "prescriptions" ($10 vouchers) for fruits and vegetables that can be redeemed at participating farmers markets and any Safeway supermarket in Washington. In the first year of the FINI grant,between April 1 and December 31, 2015, Washington SNAP participantsredeemed a total of $210,586 in fruit and vegetable incentives from farmers markets, with $200,246 redeemed at 48 different farmers market that offered matching incentive programs and $10,340 fruit and vegetable prescriptions redeemed. Prescriptions were issued by 37 different clinic sites (26 Federally Qualified Health Centers and 11 WIC offices) in partnership with 11 farmers markets. The estimated economic impact of these fruit and vegetable incentives is $376,949, based on USDA's estimate that for every SNAP dollar spent, $1.79 is generated in the local economy. Objectives #1 and #2: ACTIVITIES -DOH and its FINI subrecipients implemented the following types of SNAP fruit and vegetable (FV)incentives: matching incentives in 48 farmers markets (FM), one CSA Good Food Bags program, and one prescription (Rx)incentive program with 11 FM. City of Seattle transitioned 18 FM across King County from manual data collection of EBT transactions and incentive distribution to using a mobile data collection application that works on a variety of devices. Due to delays in federal funding, the supermarket rebate (Catalina coupon incentive) andFVRx incentive with supermarkets were not implemented. However, DOH and Safeway made progress on planning these incentive programs by: verifyingand finalizing the menu of eligibleFV that will qualify for the incentives;designing the FVRx voucher to meet FNS requirements; anddesigning theRx incentive redemption tracking system. SUMMARY STATISTICS- Forty-eight (48) FM and one CSA across nine counties offered FV matching incentives programs to SNAP participants. Thirty-seven different clinic sites (26 clinics and 11 WIC offices) in four counties issuedFV Rxto SNAP participants during one-on-one clinic appointments.From April 1 to December 31, 2015, SNAP recipients redeemed $200,246 in FM matching incentives. During the same time, SNAP participants redeemed 1,034FV Rx($10,340) at the FM. Additionally, 18FM across King County transitioned from pen-and-paper data collection of EBT transactions and incentive distribution to using a mobile data collection applicationthat works on a variety of devices (iOS and Android). The application allows the markets to create and customize fillable forms and efficiently capture, store and manage a variety of information about the market incentive programs. DOH and UW-CPHN willscale up use of devices andapplications for data collection purposes in 2016-17. OUTCOMES - SNAP participants redeemed a total of $210,586 in FV incentives from FM; $200,246 were redeemed from FM matching incentives programs and $10,340 were redeemed from FV Rx programs offered through FM. The estimated economic impact of these fruit and vegetable incentives is $376,949, based on USDA's estimate that for every SNAP dollar spent, $1.79 is generated in the local economy. Objective #3: ACTIVITIES - UnitedHealthcare Community Plan (UHCCP) implemented provider-to-patient and community engagement strategies to distribute and redeem the FV Rx. Patients who met with 209 key staff at 37 participating providers (FQHCs and WIC sites) were engaged in healthy eating behavior change conversations utilizing the FV Rx voucher. Prescription wereredeemable at selectat FM where UHCCP offered additional nutrition education, recipes, and food preparation information. SUMMARY STATISTICS& OUTCOMES- Between April 1and December 31, 2015, one major health insurer distributed fruit and vegetable prescriptions to SNAP-participating patients. Thirty-seven providers (26 clinics and 11 WIC offices) engaged 18,100 participants in healthy eating conversations, utilizing the fruit and vegetable prescription voucher. UHCCP participated in 66 FM events at 11 different markets in four counties. A total of 1,457 (8%) FV Rx were redeemed at these FM events, with 1,034 specifically from SNAP participants. Objective #4: ACTIVITIES - Due to delays in federal funding, DOH did not implement the Rx incentive program with supermarkets. This impacted the planned activities of Yakima Valley Memorial Hospital, Spokane Regional Health District, Odessa Brown Children's Clinic, and the SNAP-Ed Health Outcomes clinics. However, during the reporting period, DOH worked with these healthcare partners to develop strategies and practices to screen for SNAP participation in a variety of settings (clinical, community, classroom) in order to distribute the FV Rx to SNAP participants. SUMMARY STATISTICS & OUTCOMES - In collaboration with DOH, healthcare partners developed strategies and practices to screen for SNAP participation in a variety of settings (clinical, community, classroom) in order to distribute the fruit and vegetable prescription to eligible individuals (SNAP participants). Healthcare partners are going to screen for current SNAP participation in a variety of ways, depending on the setting. Objective #5: ACTIVITIES - DOH and its FINI subrecipients are working to identify meaningful strategies to engage SNAP participants and community-based organizations (CBOs)in the design, execution, andevaluation of the incentive programs. DOH partnered with AIGA (the professional association for design), Seattle Goodwill, Des Moines Food Bank, and SNAP-Ed to conduct 24 user experience interviews with SNAP participants. Information collectedby the interviews is informing the design of communication and outreach materials to raise awareness about theFV incentive programs. DOH convened a FINI Advisory Network that includes community representatives andCBOsdirectly involved in program implementation. The Advisory Network provides input on FINI activities, quality improvement efforts, and sustainability planning. Northwest Harvest, WithinReach, OneAmerica, and Got Green are examples of keyCBOs that will facilitate the engagement and input of SNAP participants and community residents. Additionally, subrecipients have developed a number of strategies to engage SNAP participants in the design and executionof the incentive programs. FM in King and Pierce counties are planning to utilize a SNAP peer-to-peer model to educate customers about the incentive programs and how to use them. Finally, DOH drafted a statewide evaluation plan that includes plans to include SNAP participants in the evaluation process. SUMMARY STATISTICS& OUTCOMES- DOH and project partnersdocumented strategies to engage SNAP participants and community-based organizations in the design, execution, andevaluation of the incentive programs. DOH and its FINI partners are going to use a variety of ways to engage SNAP participants and CBOs, including evaluation activities and peer-to-peer models.

Publications

  • Type: Conference Papers and Presentations Status: Submitted Year Published: 2016 Citation: Bridget Igoe and Jessica Marcinkevage. Evaluating Nutrition Incentive Programs Impact on Fruit and Vegetable Consumption and Food Access Among SNAP Shoppers. Conference Abstract. American Public Health Association (APHA) 2016 Conference, Food and Nutrition section. Submitted February 24, 2016.
  • Type: Other Status: Submitted Year Published: 2016 Citation: Bridget Igoe, Dennis McDermot, and Mandy Stahre. Strengthening the Connection Between the Supplemental Nutrition Assistance Program (SNAP) and Farmers Markets. GIS Snapshot, GIS Snapshots in CDCs Preventing Chronic Disease Journal. Submitted March 24, 2016.