Progress 09/01/19 to 08/31/23
Outputs
Target Audience: PPR Participants During the grant period of 9/1/2019 - 8/31/2023, 786 participants (enrolled adult members of Navajo Nation (AI/AN) were served by the Navajo FVRx program under GusNIP funding, which includes receiving food vouchers and health education / nutrition coaching session(s). We also wanted to note that the number of beneficiaries of the program is higher than the number of individuals for whom we have complete participant-reported evaluation data. Many participants refuse to partake in the baseline and exit surveys while enrolled in the program. Furthermore, given the largely paper-based recording system across Navajo Nation, at times prescribing teams will have enrolled participants but have not logged their key health metrics. This is not a majority of participants, but we wanted to note the discrepancy between beneficiaries of the GusNIP-funded program and those included in the full set of evaluation measures. Firms (Brick & Mortar Stores and Farmers' Markets) During the grant period of 9/1/2019 - 8/31/2023, a total of 16firms were enrolled and redeeming FVRx vouchers supported by GusNIP funding. This spanned a range of different types of stores across Navajo - including small community stores, gas station markets, the Shiprock Farmers' Market and large grocery stores like Bashas Diné Market. Through our outreach at small stores, COPE was able to support these institutions to think through supply, procurement, quality assurance and customer engagement to elevate access to healthy foods across Navajo Nation. This contributes to a long-term goal of ensuring Navajo families are able to get high quality, healthy foods as close to home as possible and at a diversity of retailers across Navajo Nation. The vast majority of store owners and customers are enrolled members of the Navajo Nation (AI/AN). Changes/Problems:
Nothing Reported
What opportunities for training and professional development has the project provided? The team undertook several professional development and training activities over the grant period. These opportunities allowed us to share knowledge among our team as well as to learn new skills. Our team - including both the programmatic implementation team and evaluation team - participated in the following opportunities: NTAE-Facilitated Communities of Practice PPR Community of Practice Corner Store Community of Practice External Evaluators Community of Practice NTAE Nutrition Incentive Hub Annual Convenings GusNIP/FINI Annual Project Directors' Meeting Webinars, Conferences and Workshops: National Grocers Association Show Conference on Native American Nutrition National Produce Prescription Collaborative National Convening National Association of Corner Stores Virtual Convening CDC DNPAO Webinars on Writing for Publication Center for American Indian and Alaska Native Diabetes Translation Research Webinars (COPE presented on occasion) Indian Country ECHO Webinars and Workshops Diabetes ECHO Care and Access for Pregnant People ECHO Maternal and Child Health ECHO CDC Division of Nutrition, Physical Activity, Obesity (DNPAO) Networking Calls on Nutrition and Programmatic Sustainability Navajo Nation Human Subjects Research Review Board (NNHRRB) Annual Meeting How have the results been disseminated to communities of interest? Regular Meetings with Implementing/Prescribing Teams and Redemption Sites: While COPE administers the Navajo FVRx Program, the front-line providers have included Community Health Workers and clinic-based staff. These teams directly engage participants so we know it's essential to communicate findings, lessons learned and best practices back to the sites themselves. We have conducted monthly or quarterly meetings with each implementing team (based on their preference) and have been working to distill our data to site-specific metrics that help to inform their engagement with participants. We also regularly met with all FVRx redemption sites by traveling across Navajo to stores and farmers' markets to get feedback on the program and trouble-shoot any issues with voucher processing. Regular Reporting to the Navajo Nation Human Research Review Board and Presentations on Navajo FVRx to the Annual NNHRRB Meeting: All data collection conducted on Navajo Nation and with Navajo Nation citizens is required to be reviewed and approved by the NNHRRB. COPE provides updates on Navajo FVRx, its progress and its impact on the community in regular quarterly and annual updates to the NNHRRB. As an organization with an open NNHRRB protocol (covering Navajo FVRx), COPE also presents at the annual NNHRRB conference, which is intended to disseminate progress out to the community. Presentation to Navajo Nation Agency Councils: Throughout the course of this grant, COPE presented on the grant and its progress to Navajo Nation Agency Councils. This included update presentations in 2021 and 2023. Presentations to Other Tribal Communities Interested in PPR Programs: As one of the first PPR programs implemented in a rural, tribal community, COPE is interested in ensuring our experience and findings are disseminated to other tribal nations. COPE has made presentations about the FVRx program to communities in our area (Ute Mountain, White Mountain Apache, Zuni Pueblo) and also had the opportunity to present to many communities through webinars, such as ones hosted by the Indigenous Food and Agriculture Initiative and the National Grocers' Association, the National Indian Health Board and the Center for American Indian and Alaska Native Diabetes Translation Research. Meetings with PPR Programs Across New Mexico: COPE regularly met with other USDA/FINI-funded PPR programs in New Mexico to share results and lessons learned during the reporting year. COPE's FVRx program is more mature than some other programs in the state, so it has been helpful for us to be able to talk through key lessons from various stages of program growth, including results from the current program. We have also shared our findings back with the State of New Mexico, which has launched a state-funded program and is planning to further scale this program up in the future. Presentations to National PPR Community: Over the course of this grant, COPE had the opportunity to present to the national PPR community through a variety of fora, including NTAE Nutrition Incentive Hub convenings and communities of practice, convenings with the Tufts Center for Nutrition and with the National Produce Prescription Collaborative (NPPC). In these national fora, COPE has presented on the progress of the Navajo FVRx program and has aimed to ensure that the dialogue around PPRs includes the opportunities and challenges specific to rural communities, which may look different from more urban, technology-connected settings. Participation in the Indian Health Service Advisory Committee for an IHS PPR Pilot: In the Spring of 2022, the Indian Health Service was authorized $3 million to create, in coordination with Tribes and urban Indian Health Organizations, a pilot PPR program to increase access to produce and traditional foods in Native communities. The IHS team driving development of the pilot asked COPE to be part of the planning committee and we participate in monthly calls to share experiences from the Navajo FVRx program to inform the broader IHS pilot. Now that grants have been made, COPE continues to provide TA as part of the IHS program's evaluation working group. What do you plan to do during the next reporting period to accomplish the goals?
Nothing Reported
Impacts
What was accomplished under these goals?
The long-term project goal is to strengthen regional food systems and reduce diet-related health disparities in Navajo Nation. To achieve this, COPE aimed to increase the purchase of fruits and vegetables and improve health outcomes among families through its Produce Prescription Program (PPR) - the Navajo Fruit and Vegetable Prescription Program (Navajo FVRx). Under this award, COPE worked with participating healthcare entities to enroll participants, namely Navajo tribal members residing in New Mexico, Arizona, and Utah who receive tribal healthcare services. Key Outcomes Between September 1, 2019 - August 30, 2023, COPE delivered FVRx to 786participants through GusNIP funding across Navajo Nation - including the Arizona, New Mexico, and Utah sections.This included enrollment from eleven implementing/enrolling sites throughout the course of the grant. Among GusNIP participants, intake and exit data were successfully collected for 110 individuals. 183 intake surveys were collected, and 110 exit surveys were completed, resulting in 110 matched pre/post pairs. Changes in fruit and vegetable consumption as well as food security status are summarized in the table below. Change in Fruit/Vegetable Consumption and Food Security Among Those with Pre-Post Data, n=110 Indicator Baseline Exit Fruit and Vegetables (Average # cups /day) 2.59 2.53 Food Security Score (using USDA HFSSM Short-Form) 1.7 1.0 * Using a p-value of 0.05, the change in the mean results at baseline and exit was not found to be statistically significant with this sample size This grant was COPE's first from the GusNIP program and also marked the first time that the Navajo FVRx had specifically used the Dietary Screener Questionnaire and USDA HFSSM Short-Form tools to collect data related to food security and consumption status. The results presented in the table above from the USDA HFSSM Short-Form, although not statistically significant does demonstrate a downward trend and decrease in food insecurity scores. However, there is no evidence of a change in the DSQ pre and post values. Qualitative data collected from COPE Navajo FVRx participants and observational data from enrollment teams, indicated more changes from beginning to end of the program. This discordance from qualitative data and the quantitative data may indicate that the tools may present challenges when used in our population. More research is needed to understand perspectives of our participants with respect to the use of the tools. We know that work is ongoing to determine a strengths-based food security questionnaire for use in tribal communities that is likely to better represent the lived experience of participants. More investigation may also be helpful in determining how best to utilize the DSQ tool within a population such as ours, particularly given the reliance on 30-day recall. Other Major Accomplishments Alongside the data reported above, as one of the first PPR programs implemented in a rural, tribal community, COPE feels strongly that we should ensure our experience and findings are disseminated to other tribal nations and rural communities, particularly to inform long-term sustainable initiatives to improve health and food security. COPE made significant progress in this area over the grant period through opportunities to inform federal and regional initiatives that have implications for the expansion and sustainability of PPR programs serving tribal communities. IHS PPR Pilot: In the Spring of 2022, the Indian Health Service was authorized $3 million to create, in coordination with Tribes and urban Indian Health Organizations, a pilot PPR program to increase access to produce and traditional foods in Native communities. The IHS team driving development of the pilot asked COPE to be part of the planning committee and we participate in monthly calls to share experiences from the Navajo FVRx program to inform the broader IHS pilot. In July 2023, IHS awarded five tribes and tribal organizations with funding to implement produce prescription programs in their communities. These five-year awards will contribute essential information to the broader community about PPR implementation in tribal communities. Now that grants have been made, COPE continues to provide TA as part of the IHS program's evaluation working group. State of New Mexico's FVRx Program: In early 2022, the Governor of New Mexico released a five-year?Food, Farm and Hunger Initiative?that aims to ensure food insecure New Mexicans have access to healthy meals. As part of this initiative, the State of New Mexico launched a pilot state-funded PPR program that will focus on serving tribal, rural and frontier communities in the state. COPE met with state officials regularly to share our experience and provide insight about the particular considerations relevant to delivering PPR programs to tribal communities in this region. Through sharing information with legislators and other administration officials throughout New Mexico, the program has recently requested a budget increase for this program in further years.
Publications
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Progress 09/01/21 to 08/31/22
Outputs
Target Audience:PPR Participants During the reporting period of 9/1/2021 - 8/31/2022, 250 adult participants were enrolled in Navajo FVRx and supported by GusNIP funding - or were enrolled before the reporting period but actively in the program during the reporting period. These patients met the following eligibility requirements: Receive care at a participating healthcare facility; An enrolled adult member of the Navajo Nation; Diagnosed with, or at risk of developing, a diet-related health condition; and Either: enrolled in SNAP benefits or FDPIR; or enrolled in medical assistance under a State plan. The number of beneficiaries of the FVRx program dramatically increased over the previous reporting year as implementing/prescribing sites were able to extend more capacity to non-COVID health promotion activities. COPE continues to work with sites to overcome high staff turnover within the health system - and the implications this has on capacity to implement FVRx - but it has been impactful to see the upsurge in enrolled participants over the previous reporting year. We also wanted to note that the number of beneficiaries of the program is higher than the number of individuals for whom we have complete participant-reported evaluation data. Many participants refuse to partake in the baseline and exit surveys while enrolled in the program. Furthermore, given the largely paper-based recording system across Navajo Nation, at times prescribing teams will have enrolled participants but have not logged their key health metrics. This is not a majority of participants, but we wanted to note the discrepancy between beneficiaries of the GusNIP-funded program and those included in the full set of evaluation measures. Firms (Brick & Mortar Stores) During the reporting period of 9/1/2021 - 8/31/2022, a total of twelve firms were enrolled and redeeming FVRx vouchers supported by GusNIP funding. This spanned a range of different types of stores across Navajo - including small community stores, gas station markets, the Shiprock Farmers' Market, and large grocery stores like Bashas. Through our outreach at small stores, COPE was also able to reach several community members who frequent stores for supplies on Navajo Nation. The vast majority of store owners and customers are enrolled members of the Navajo Nation. Changes/Problems:One particular challenge that we have noted for our NTAE colleagues is capacity challenges particularly at Northern Navajo Medical Center (NNMC). The Diabetes in Pregnancy program at NNMC had been a key partner over the early years of the FVRx program and was one of the largest and most consistent cohorts over several years. However, the original champion for the program at NNMC retired in the summer of 2021. Since this individual's departure, the program has had challenges in maintaining the FVRx program, at least within the OB/Diabetes in Pregnancy cohort. It is likely that the team will cease enrollments for some time at the end of 2022. During the last reporting year, the team at NNMC was not able to work with their enrolled participants to complete any baseline or exit surveys, which was a disappointment. While this development has been challenging, we are pursuing other teams to partner with within the facility, particularly given the needs and demand among families in the surrounding community. Overall, this staffing transition has highlighted the importance of succession planning for early champions and the need to identify different incentive structures (e.g., serving the community, opportunities for publication, etc.) for participation in PPRs among stretched healthcare workers and to avoid thinking that one-size-fits-all. What opportunities for training and professional development has the project provided?The team undertook several professional development and training activities over this reporting period. These opportunities allowed us to share knowledge among our team as well as to learn new skills. Our team availed of the following opportunities: GusNIP PPR Community of Practice meetings (monthly convenings attended by Kymie Thomas, Robert Aslburg, and Katie Callahan) GusNIP Nutrition Incentive Hub Corner Store Community of Practice meetings (monthly convenings attended by Robert Alsburg) GusNIP/FINI Project Directors' Meeting (attended by Katie Callahan, October 2022) GusNIP External Evaluators Community of Practice meetings (ongoing meetings attended by Katie Callahan, Carmen George [COPE's External Evaluator], and Sonya Shin [COPE's External Evaluator]) Webinars, Conferences, and Workshops: Conference on Native American Nutrition (attended by Kymie Thomas and Katie Callahan, May 2023) National Produce Prescription Collaborative National Convening (attended by Robert Alsburg, Carmen George [COPE's External Evaluator], and Katie Callahan, September 2022) CDC DNPAO Networking Calls on Nutrition and Programmatic Sustainability (ongoing meetings attended by Katie Callahan) How have the results been disseminated to communities of interest? Regular Meetings with Implementing/Prescribing Teams and Redemption Sites: While COPE administers the Navajo FVRx Program, the front-line providers include Community Health Workers and clinic-based staff. These teams directly engage participants, so we know it's essential to communicate findings, lessons learned, and best practices back to the sites themselves. We conduct monthly or quarterly meetings with each implementing team (based on their preference). We have been working to distill our data into site-specific metrics that help to inform their engagement with participants. We also regularly meet with all FVRx redemption sites by traveling across Navajo to stores and farmers' markets to get feedback on the program and troubleshoot any issues with voucher processing. Participation in the Indian Health Service Planning Committee for an IHS PPR Pilot: In the Spring of 2022, the Indian Health Service was authorized $3 million to create, in coordination with Tribes and Urban Indian Health Organizations, a pilot PPR program to increase access to produce and traditional foods in Native communities. The IHS team driving the development of the pilot asked COPE to be part of the planning committee, and we participated in monthly calls to share experiences from the Navajo FVRx program to inform the broader IHS pilot. Presentations to Other Tribal Communities Interested in PPR Programs: As one of the first PPR programs implemented in a rural tribal community, COPE is interested in ensuring our experience and findings are disseminated to other tribal nations. COPE has made presentations about the FVRx program to communities in our area (Ute Mountain, Zuni Pueblo) and also had the opportunity to present to many communities through a webinar hosted by the Indigenous Food and Agriculture Initiative and the National Grocers' Association (May 2022). Meetings with PPR Programs Across New Mexico: COPE met with other GusNIP/FINI-funded PPR programs in New Mexico to share results and lessons learned during the reporting year. COPE's FVRx program is more mature than programs such as FreshRx in New Mexico, so it has been helpful for us to be able to talk through key lessons from various stages of program growth, including results from the current program. We have also shared our findings with the State of New Mexico, which is preparing to scale up a state-wide FVRx program in the future. Presentation at the National Produce Prescription Collaborative's National Convening around the White House Conference on Hunger, Nutrition and Health: Alongside the White House meeting in September 2022, the National Produce Prescription Collaborative hosted a meeting in Washington, DC to bring together PPR implementers/funders and align on policy actions that could help promote sustainable programming. COPE presented at the convening and aimed to ensure that the dialogue around PPRs includes the opportunities and challenges specific to rural communities, which may look different from more urban, technology-connected settings. What do you plan to do during the next reporting period to accomplish the goals?In April 2022, COPE received a one-year no-cost extension on this award, extending the grant period to August 31, 2023. This was a welcome development given the delays in programmatic implementation and evaluation caused by COVID, particularly in the first two years of the pandemic. However, given enrollment in this reporting year, COPE feels confident that the one-year extension will allow us to meet the grant objectives by the end date in 2023.
Impacts
What was accomplished under these goals?
The long-term project goal is to strengthen regional food systems and reduce diet-related health disparities in Navajo Nation. To achieve this, COPE aims to increase the purchase of fruits and vegetables and improve health outcomes among families through its Produce Prescription Program (PPR) - the Navajo Fruit and Vegetable Prescription Program (Navajo FVRx). Under this award, COPE will work with participating healthcare entities to enroll 285 participants, namely Navajo tribal members residing in New Mexico, Arizona, and Utah, who receive tribal healthcare services. While COVID continues to impact the health system on Navajo Nation, this reporting period showed resilience within COPE's FVRx program - and across the Navajo Nation health system overall. COPE was able to make much more progress with partner sites around the enrollment of participants in the FVRx program, demonstrating a 150% increase in program beneficiaries over the prior reporting year. Between September 1, 2021 - August 31, 2022, COPE delivered FVRx to 250 participants through GusNIP funding across Arizona, New Mexico, and Utah. This includes participants who were enrolled in the reporting year, and those who were enrolled before the reporting period but actively in the program during the reporting period. Many clinical sites on Navajo continue to face staffing shortages, but among those that had participated in FVRx before the pandemic, most were eager to either expand their cohorts again or re-start if they had been on a pause during the early part of COVID. We have also trained new firms - including Tsaile Health Center and Crownpoint Healthcare Facility - who plan to start enrolling participants in early 2023. As one of the first PPR programs implemented in a rural tribal community, COPE feels strongly that we should ensure our experience and findings are disseminated to other tribal nations and rural communities, particularly to inform long-term sustainable initiatives to improve health and food security. COPE made significant progress in this area through opportunities to inform federal and state initiatives in the reporting year. IHS PPR Pilot: In the Spring of 2022, the Indian Health Service was authorized $3 million to create, in coordination with Tribes and Urban Indian Health Organizations, a pilot PPR program to increase access to produce and traditional foods in Native communities. The IHS team driving the development of the pilot asked COPE to be part of the planning committee, and we participated in monthly calls to share experiences from the Navajo FVRx program to inform the broader IHS pilot. State of New Mexico's FVRx Program: In early 2022, the Governor of New Mexico released a five-yearFood, Farm, and Hunger Initiativethat aims to ensure food-insecure New Mexicans have access to healthy meals. As part of this initiative, the State of New Mexico is developing a state-funded PPR program that will focus on serving tribal, rural, and frontier communities in the state. COPE met with state officials regularly to share our experience and provide insight about the particular considerations relevant to delivering PPR programs to tribal communities in this region. Key Outcomes Objective 1: 90% of Patients Will Report an Increase in Fruit and Vegetable Consumption at FVRx Completion Compared with Baseline: Among those with pre-post data (33 participants with pre-post data), 64% reported an increase in fruit and vegetable consumption atFVRxcompletion. Objective 2: 75% of Families will Report a Decrease in Household Food Insecurity at FVRx Completion Compared to Baseline: Among those with pre-post data (33 participants with pre-post data), approximately 33% of these patients reported a decrease in household food insecurity atFVRxcompletion compared with baseline. Summary Statistics During the reporting period of 9/1/2021 - 8/31/2022, a total of 250 adult participants were beneficiaries of the Navajo FVRx program through funding from GusNIP. This includes participants who were enrolled in the reporting year, and those who were enrolled before the reporting period but actively in the program during the reporting period. Distribution across enrolling firms (clinics) is summarized in Table 1. Table 1: GusNIP Enrollment by firm Site # participants enrolled (%) Chinle Public Health Nursing 15 (6.0) Chinle Women's Health 8 (3.2) Crownpoint Community Health Representatives (CHRs) 31 (12.4) Gallup Indian Medical Center 93 (37.2) Utah Navajo Health Systems (Montezuma Creek) 9 (3.6) Four Corners Regional Health Center (Red Mesa) 12 (4.8) Northern Navajo Medical Center 64 (25.6) Piñon Health Center 7 (2.8) Pine Hill Health Center (Ramah) 11 (4.4) TOTAL 250 Among participants, baseline data were successfully collected for 250 individuals. Baseline participant characteristics are summarized in Table 2. Table 2: Baseline characteristics and Program Participation of GusNIP participants, n=250 Characteristics (n, if not equal to 250) N (%) or Average (SD) Median [range] Gender Female 250 (100%) Age, median (IQR; range) (n=95) 31 (28-35; 17-44) Educational level (n=73) Middle School 4 (5.5%) High School 21 (28.8%) Vocational degree 9 (12.3%) Bachelor's degree/College 39 (53.4%) State of residence (n=96) NM 62 (64.6%) AZ 28 (29.2%) UT 6 (6.2%) Maternity status at time of enrollment Pregnant 154 (61.6%) Post-partum 66 (26.4%) Unknown status 30 (12%) Baseline health habits (n=71) Fruit (Average daily frequency consumed) 1.5 (0.9) Vegetables (Average daily frequency consumed) 1.7 (0.8) Fruit and Vegetables (Average daily frequency consumed) 3.1 (1.5) Baseline household characteristics are summarized in Table 3. Table 3: Baseline Household Characteristics of GusNIP participants, n=250 Characteristics (n, if not equal to 250) N (%) or Average (SD) Median [range] Household size, median # people (IQR; range) (n=96) 4 (3-5; 1-12) Household food insecurity (n=73) Very Low Food Secure 4 (5.5%) Low Food Secure 29 (39.7%) Food Secure 40 (54.8%) Benefits Being Received by Participant (n=96) SNAP / EBT / Food stamps only 16 (16.7%) SNAP / EBT / Food stamps with: WIC 18 (18.7%) WIC and FDPIR 1 (1%) WIC and TANF 1 (1%) WIC only 16 (16.7%) None (reported no food assistance benefit) 44 (45.8%) Among GusNIP participants, intake and exit data were successfully collected for 33 individuals (i.e., intake and exit). Changes in fruit and vegetable consumption as well as food security status, are summarized in Table 4. Table 4: Change in Health Habits and Food Security Among Those with Pre-Post Data, n=33 Characteristics (n, if not equal to 33) Baseline Exit P-value Fruit (Average # cups / day) 1.3 (0.8) 1.2 (0.7) 0.52 Vegetables (Average # cups / day) 1.5 (0.7) 1.6 (0.4) 0.47 Fruit and Vegetables (Average # cups /day) 2.8 (1.3) 2.7 (1.1) 0.87 Food Security Status[1] (n=30) Very Low Food Secure 6.7% 0% Low Food Secure 33.3% 20% Food Secure 60% 80% P-value = 0.66 if we compare Food Secure vs Food Insecure (combining Low Food Secure and Very Low Food Secure). [1] Note on Food Security Variable: The final score is the sum of all affirmative responses to the 6-item, all missing responses among those 6-item did not contribute to increase the "yes" score, which potentially lead to overestimate the "High food security" category
Publications
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Progress 09/01/20 to 08/31/21
Outputs
Target Audience: PPR Participants During the reporting period of 9/1/2020 - 8/31/2021, 64 women were enrolled. An additional 36 women were beneficiaries (i.e., enrolled before the reporting period but actively in the program during the reporting period) of the Navajo FVRx Program and supported by GusNIP funding. These patients met the following eligibility requirements: Receive care at a participating healthcare facility; An enrolled adult member of the Navajo Nation; Diagnosed with, or at risk of developing, a diet-related health condition; and Either: enrolled in SNAP benefits or FDPIR; or enrolled in medical assistance under a State plan. The number of beneficiaries of the FVRx program decreased over the previous reporting year due to the COVID pandemic. Throughout the reporting year, Navajo Nation went through two significant surges in cases. Those surges were the spike around the fall/winter of 2020 and the spike that followed the emergence of the Delta strain across the United States. During surge periods, prescribing sites have been difficult to enroll new patients and keep them engaged in monthly education sessions, particularly when meeting in person has been restricted. COPE and our partner prescribing sites have also seen significant staff turnover throughout the reporting period, aligning with national trends within the healthcare and public health space. This impacted the ability to navigate some of the challenges related to COVID, but we are now piloting alternative approaches (see Section 4 above) to expand participation despite the ongoing pandemic. Firms (Brick & Mortar Stores) During the reporting period of 9/1/2020 - 8/31/2021, a total of nine firms were enrolled and redeeming FVRx vouchers supported by GusNIP funding. This spanned a range of different types of stores across Navajo - including small community stores, gas station markets, and large grocery stores like Bashas. Through our outreach at small stores, COPE was also able to reach several community members who frequent stores for supplies on Navajo Nation. The majority of store owners and customers are enrolled members of the Navajo Nation. These individuals would have found information on the spread and precautions against COVID-19 at the stores, been able to use hand sanitizer stations installed by COPE and pick up free masks delivered by COPE. Changes/Problems: COVID continues to have an impact on our programming in the Navajo Nation. Although Navajo Nation had started to roll back some of its previous COVID restrictions, the recent surge in cases from the delta-variant have appropriately shifted our partners' focus back on COVID prevention measures and the vaccine rollout. Along with making in-person meetings difficult, this makes it challenging to plan activities for the coming months, as several of our activities are designed to be carried out in person. It has also been challenging for partners who are willing to meet to find spaces for engagement that allow for social distancing. We continue to meet with our partners virtually and safely where possible. Due to these challenges, we have enrolled fewer participants in the program than expected and believe the expenditure on food vouchers is lower than expected. What opportunities for training and professional development has the project provided? The team undertook several professional development and training activities over this reporting period. These opportunities allowed us to share knowledge among our team as well as to learn new skills. Our team availed of the following opportunities: GusNIP PPR Community of Practice meetings (monthly convenings attended by Kymie Thomas, Robert Aslburg, Katie Callahan and Carmen George) GusNIP Nutrition Incentive Hub Corner Store Community of Practice meetings (meetings in December 2020, February 2021, April 2021, and June 2021 - attended by Robert Alsburg) GusNIP/FINI Project Directors' Meeting (attended by Katie Callahan) GusNIP External Evaluators Community of Practice meetings (July 2021, September 2021, and November 2021 - attended by Carmen George and Sonya Shin) Webinars, Conferences and Workshops: National Association of Corner Stores Virtual Convening (October 2020, attended by Robert Alsburg) National Produce Prescription Collaborative Meetings (attended by Kymie Thomas and Carmen George) CDC DNPAO National Training - Leading the Charge for a Healthy Nation (May 2021, attended by Robert Alsburg and Carmen George) CDC DNPAO Writing for Publication Webinar Series (attended by Kymie Thomas) How have the results been disseminated to communities of interest? Quarterly FVRx Webinars: Quarterly, COPE organizes webinars for the entire Navajo FVRx community. This includes prescribers (clinicians and community health workers), health educators at participating sites and other site staff supporting the program (i.e., voucher administration, etc.) The purpose of these calls is to provide programmatic updates - including updates specific to GusNIP, facilitate opportunities for sites to learn from one another, and to present data from the program back to the community. These webinars took place during the reporting year, in October 2020, March 2021, May 2021, and July 2021. GusNIP evaluation data is a key element of these webinars. Presentation to Northern Navajo Agency Council Meeting - March 2021: In March, COPE presented at the Northern Navajo Agency Council Meeting (one of Navajo Nation's five Agencies) on the progress of its various programs, including FVRx. Given that much of the FVRx vouchers for participants in the Northern Navajo Agency are supported by GusNIP funds, this was a significant opportunity to highlight the funding COPE had received and the grant's objectives. Meetings with PPR Programs Across New Mexico: COPE met with other GusNIP/FINI-funded PPR programs in New Mexico to share results and lessons learned during the reporting year. COPE's FVRx program is more mature than programs such as FreshRx in New Mexico, so it has been helpful for us to be able to talk through key lessons from various stages of program growth, including results from the current program. Presentation on FVRx to Ute Mountain Ute Community: As the first PPR program in a rural tribal community, COPE is interested in ensuring that lessons and data from the program are disseminated in a way that could inform other PPR programs in tribal communities. During the reporting year, we met with Public Health Nurses in the Ute Mountain Ute community to share data about the Navajo FVRx program - including data specific to GusNIP - as the Ute Mountain community starts to think through implementation of a similar program. Presentations on National and Regional Webinars and Workshops: Rx for Fresh Fruits and Vegetables in Idaho (September 2020, presentation by Kymie Thomas) National Association of Corner Stores Virtual Convening (October 2020, presentation by Robert Alsburg) National Indian Health Board Public Health in Indian Country Capacity Scan Report Meeting (October 2020, presentation by Kymie Thomas) Tufts Center for Nutrition: Food is Medicine Panel Discussion (March 2021, presentation by Kymie Thomas) Nutrition Incentive Hub National Convening (March 2021, presentation on food sovereignty by Kymie Thomas, participation by Carmen George) What do you plan to do during the next reporting period to accomplish the goals? COVID continues to pose challenges to our PPR programming through FVRx. During this reporting period, we saw the major COVID spike of fall 2020/winter 2021, followed by a broad roll-out of vaccinations, but then the Delta surge starting in late summer 2021. These surges have been disruptive to programming in an unprecedented way. However, we also recognize that almost two years into the pandemic, it is essential to continue piloting alternative approaches to reach families with the FVRx program effectively. Given rising food insecurity during the pandemic, we also know that these services are more critical than ever. Some of the adaptations we are working on include the development of food demonstrations and nutrition educations sessions with Navajo social media influencers and Navajo individuals who have cooking programs on Facebook, Instagram, and TikTok. We know that younger families enrolled in FVRx are more likely to want to access digital content, particularly if they cannot meet in person for health education sessions. COPE also just transitioned healthcare teams to tablet-based data collection at the end of this reporting period. This allows more secure and accurate data entry, compared to the manual entry of paper forms which has been the norm for the last several years of the program. This transition is helping healthcare teams enter data faster, safer, and more precisely. We look forward to seeing the evaluation data at the end of the next reporting period to reflect a complete tablet transition. COPE is also a grantee for the GusNIP COVID Relief and Recovery (CRR) funding stream in 2021. While reported separately, this program will allow COPE to expand eligibility criteria for the FVRx program to reach more adults beyond our current maternal cohort, including those affected by COVID or who have a diagnosis of cancer, diabetes, hypertension, or obesity.
Impacts
What was accomplished under these goals?
The long-term project goal is to strengthen regional food systems and reduce diet-related health disparities in Navajo Nation. To achieve this, we intend to increase the purchase of fruits and vegetables and improve health outcomes among families in Navajo Nation through a Produce Prescription Program (PPR). Whereby participating healthcare entities will enroll 285 participants over three years, namely Navajo tribal members residing in New Mexico and Utah who receive tribal healthcare services. This year, we are also including participants residing in Arizona. COPE has continued to implement the Fruit and Vegetable Prescription (FVRx) Program during this reporting period despite the public health crisis stemming from the COVID-19 pandemic. Our partners have continued responding to community needs by referring and enrolling patients, issuing FVRx vouchers, delivering health coaching sessions, and ensuring that local stores are well-stocked and able to open for business safely. Since September 2020, COPE has succeeded in enrolling 64 participants in FVRx through GusNIP funding across Arizona, New Mexico, and Utah. An additional 36 women were beneficiaries (i.e., enrolled before the reporting period but actively in the program during the reporting period). When COVID-19 cases decreased over the summer of 2021, COPE began to reconnect with clinical teams. These teams include the Crownpoint Community Health Representative team, Four Corners Regional Health Center team, Gallup Indian Medical Center team, Northern Navajo Medical Center team, Pine Hill Health Center team, and Utah Navajo Health System. These facilities had paused FVRx programming for some time due to COVID-19 and could now consider enrolling new patients. Our team has worked closely with store owners to help ensure they comply with COVID-19 prevention guidelines to stay open and serve their communities. In the coming year, COPE will focus on renewing agreements with stores, updating layouts, providing assistance with marketing, and equipping stores to redeem electronic prescription vouchers. During the reporting period, COPE has introduced electronic tablets to facilitate data collection at health facilities. However, due to disruptions to trainings caused by COVID-19, and elongated IRB review of the updated tablet forms by the Navajo Nation Human Research Review Board, the GusNIP data collection forms were only being used by a limited number of facilities by the end of the reporting period. The tablet-based forms have been rolled out more widely in the fourth quarter of 2021. This year, COPE's successes have included: Acquiring permission to expand the FVRx Program under GusNIP to residents of Arizona. Receiving Institutional Review Board (IRB) approval for GusNIP data collection forms. Leveraging additional funds for our food access programming. Completion of a case study on our PPR project. We are grateful that NIFA could expand the eligibility for our GusNIP grant to include residents from Arizona as recipients of the program. We were also able to complete, submit, and receive approval from the Navajo Nation IRB for data collection created to evaluate the impact of the GusNIP grant. By demonstrating long-term funding for FVRx vouchers from GusNIP, COPE was able to secure further funds to expand eligible participants to those affected by COVID from the GusNIP COVID Relief and Response opportunity. We also successfully secured funds from a private donor to support additional accompaniment for FVRx participants impacted by food insecurity and diabetes. Additionally, COPE contributed to a research paper, Strengthening food sovereignty and health with produce prescription programs: A case study in two rural tribal communities participating in GusNIP, written by the Nutrition Incentive Hub and scheduled for publication in the Journal of Agriculture, Food Systems, and Community Development, which is under review. Key Outcomes Objective 1: 90% of Patients Will Report an Increase in Fruit and Vegetable Consumption at FVRx Completion Compared with Baseline: Among those with pre-post data (14 participants with pre-post data), 64.3% of the 14 patients reported an increase in fruit and vegetable consumption at?FVRx?completion (average 5.3 times / day compared 2.4 times / day at baseline, p=0.004).? Objective 2: 75% of Families will Report a Decrease in Household Food Insecurity at FVRx Completion Compared to Baseline: Among those with pre-post data (14 participants with pre-post data), approximately 50% of these patients reported a decrease in household food insecurity at?FVRx?completion compared with baseline.?Because the program is more than a year in duration (typically enrolling women during pregnancy and lasting until the child reaches 12 months of age), the number of women with pre-post data is limited; however we anticipate larger numbers for the next reporting period. Summary Statistics During the reporting period of 9/1/2020 - 8/31/2021, a total of 64 women were enrolled and an additional 36 women were beneficiaries (i.e., enrolled prior to the reporting period but actively in the program during the reporting period) of the Navajo FVRx Program and supported by GusNIP funding. Distribution across enrolling firms (clinics) and baseline characteristics are summarized in Table 1. Table 1: Site and baseline characteristics among participants enrolled during reporting period, n=64 Characteristics (n, if not equal to 64).......N (%) Enrollment Site.......# Participants enrolled Chinle.......6 (9.4%) Crownpoint.......4 (6.2%) Gallup Indian Medical Center.......33 (51.6%) Montezuma Creek.......7 (10.9%) Four Corners Regional Health Care (Red Mesa).......11 (17.2%) Shiprock (includes NWNM First Born).......3 (4.7%) Female.......64 (100%) Age at enrollment, Average (SD).......31.7 (5.8) State of residence, n=57 NM.......30 (46.9%) AZ.......22 (34.4%) UT.......5 (7.8%) Maternal health status at time of enrollment, n=50 Post-partum.......8 (12.5%) Pre-natal.......42 (65.6%) Diabetes Type 1 DM.......- Type 2 DM.......4 (6.3%) Gestational diabetes.......37 (57.8%) No diabetes.......8 (12.5%) Unknown status.......15 (23.4%) Baseline health habits (n=31).......Average (SD) Fruit (# times / day).......2.7 (1.3) Vegetables (# times / day).......2.6 (1.3) Fruit and Vegetables (# times/day).......5.1 (2.5) Sugar-sweetened beverages # times /day).......6.7 (4.9) Water (# times / day).......5.2 (2.2) Physical activity (minutes /day).......58.6 (51.1) Sleep (hours / day).......10.5 (5.4) Screen time (hours / day).......6.7 (7.7) Of the 64 women enrolled in the project period, 45.3% were retained, i.e., completed at least 4 sessions. Given COVID-19 public emergency measures throughout the reporting period, we felt that enrollment and participation was an important achievement. In terms of program participation, participants attended a median of 3 sessions. Thirty-five (54.7%) attended 1-3 sessions, while 18 (28.1%) attended 4-6 sessions and 11 (17.2%) attended > 6 sessions.
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Progress 09/01/19 to 08/31/20
Outputs
Target Audience: Over this reporting period, COPE'sFVRxProgramhasenrolled200patientsand deliveredFVRxtooverall. These patients meet the following eligibility requirements: Receive care at a participating healthcare facility; Enrolled adult member of the Navajo Nation; Diagnosed with, or at risk of developing, a diet-related health condition; and Either: enrolled in SNAP benefitsor FDPIR;or enrolled in medical assistance under a State plan Through our outreach at small stores, COPE was able to reach several community members who frequent stores for supplies on Navajo Nation. The majority of store owners and customers are enrolled members of the Navajo Nation. These individuals would have found informationon the spread and precautions against COVID-19 at the stores, been able to use hand sanitizer stations installed by COPE, andpick upfree masksdelivered by COPE. Changes/Problems:The COVID-19 pandemic has hit Navajo Nation particularly hard. The Navajo government has responded to high rates of infection by instituting lockdowns, curfews, and restrictionsagainstcongregating groups, which have proven to play a critical role in flattening the curve.Clinical and early childhood education centers have had to close down, while several clinical staff have beenreassigned to the COVID-response.These precautions have slowed, and occasionally paused, COPE's ability toconduct outreach and training activities.As a result,FVRxenrollmentand voucher redemptionhas been lowerthan expected.COPE has also had difficulty in recruitingand retaining staff during this time of uncertainty. What opportunities for training and professional development has the project provided? The team undertook several professional development and training activitiesoverthis reporting period.These opportunities allowed us to share knowledge among our team as well as to learn newskills. Our team availed of the following opportunities: COPE Store Outreach Coordinator Janine Hoodand MEQ Coordinator Shine Saltattended the National Grocers Association Show in San Diego from February 23-26, 2020. At this three-day conference, Ms. Hoodand Ms. Salthad the opportunityto attend sessions pertinent to COPE's Produce Prescription Program, includingtalks on Promoting Healthy Eating, Food Desert Financing Options,Healthy Food Incentive Programs, and Conquering the Last Mile. The conference also included a Student Case study competition on Marketing to EBT Customers, where participants presented easier and more comfortable ways for SNAP participants and shoppers with produce prescriptions to maximize their food benefits by increasing the portion of their basket composed of fruits and vegetables. March 18, 2020: Virtual Advisory Committee Meeting (attended by Carmen George) March 19-20, 2020: Virtual Nutrition Incentive Practitioner Convention (attended by Carmen George,KymieThomas and RobertAlsburg) March 26, 2020: Virtual Coffee HouseChat & Covid 19 Strategies (attended by Carmen George,RobertAlsburgandKymieThomas) April 8, 2020:The Big Picture of SNAP EBTProcessing and Technology Webinar (attended by Carmen George) May 5, 2020:GusNIPPPR Community of Practice - first convening (attended by Carmen George) May 15, 2020: IRB Guidance for Data Collection & Evaluation Webinar (attended by Carmen George) May 28, 2020:GusNIPPPR Community of Practice #2 (attended by Carmen George) June 5, 2020: Growing Your Grassroots - EmployingLocalCommunity Leaders for SNAP and Incentive Outreach Webinar (attended by Carmen George) July 30, 2020:GusNIPPPR Community of Practice Convening(attended by Carmen George) September 24, 2020:GusNIPPPR Community of Practice Convening (attended by Carmen George) How have the results been disseminated to communities of interest? COPEhas continuedto collectintake and exit patient surveys this year.WehaveupdatedtheformswithGusNIPindicatorsand submitted them forapprovalby the Navajo Internal Review Board (IRB). With theongoingpandemic, there was a slight delay with the approval of theformsby Navajo IRB, however we anticipate the intake and exit forms will be finalizedby the end of November 2020. We have been working closely with theNational Training, Technical Assistance, Evaluation, and Information Center (NTAE)team to ensure we have included appropriateGusNIPindicators. As we continue to collect intake and exit forms, thecompleteresults are forthcoming in the following years.COPE has collected process indicators on voucher redemption guided by the Gretchen Swanson Center for Nutrition, and has shared this data with them. Following Navajo IRB review and approval of data collection and analysis, COPE will submitresearchfindings for presentation at theNavajo Nation Research Conference and other regional meetings.COPE will disseminate research resultsthrough conferences, our website, and social media channelsto reach current, former, and potential patients, healthcare providers, and policy makers. We expect this information will reach local, regional, and national audiences. What do you plan to do during the next reporting period to accomplish the goals? In order to facilitate program activities at a time when restrictions put in place in response to the COVID-19 pandemic have limited in-person contact, COPE will undertake the following activities to accomplish our goals: COPE will create videos of the Happy Homes curriculum to assist in delivering theFVRxProgram to participants. Healthcare providers deliver this evidence-based curriculum toFVRxparticipants over a 6-month period. COPE will make the videos available online and on flash-drives to allow program participants to avoid congregating for health coaching sessions by receiving education in their homes. COPEis transitioning healthcare teamsto tablet-based data collectionto facilitate more secure and accurate data entry. Healthcare teams currently submitpatientdata through paper forms, which are manually entered intoCOPE's database for analysis. At a time when completing and collecting paper forms has become difficult, COPE is helping healthcare teams switch to a system that will allow for virtual data entry, a faster, safer, and more precise way to collect information from participants.
Impacts
What was accomplished under these goals?
The long-term project goal is to strengthen regional food systems and reduce diet-related health disparities in Navajo Nation. To achievethis,we intend to increase the purchase of fruits and vegetables and improve health outcomes among families in Navajo Nation through a Produce Prescription Program (PPR), whereby participating healthcare entities will enroll a total of 285 participants over a three-year period, namely Navajo tribal members residing in New Mexicoand Utahwho receive tribal healthcare services.? During this reporting period, COPE hascontinued tosuccessfully implement theFruit and Vegetable Prescription (FVRx)Program despite the public health crisisstemmingfrom the COVID-19 pandemic.Our partners have continued responding to community needs by referring and enrolling patients, issuingFVRxvouchers, delivery health coaching sessions, and making sure that local stores are well-stocked and safely open for business.The COPEFVRxteam has worked closely with our partnerstoensure that theFVRxProgram continues byextendingFVRxexpiration dates andcontinuing with the quarterly webinars.TheCOPEFVRxProgram has been particularly valuable in ensuring access to healthy foods at a time whenindigenouscommunitieshave been disproportionally impacted by COVID, through direct infections as well as through lost employment and income.FromSeptember 2019, we have served200familiesby facilitating the distribution of9,980vouchers for healthy food and the delivery ofone monthly educationhealth coaching sessionsince September 2019 to August 2020.We have alsoassistedsmall storesby providing information on safety protocols and delivering hand sanitizer and masks for use by retailers and customers.One new store,Mickey's Save Way, wasonboardedinto the program during the reporting period.
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