Recipient Organization
UNIVERSITY OF NEW ENGLAND
11 HILLS BEACH RD
BIDDEFORD,ME 04005
Performing Department
(N/A)
Non Technical Summary
Few Americans meet dietary recommendations. Poor diet is a major contributor to increasing prevalence of diabetes and obesity, which are negatively impacting long term health, quality of life, and healthcare costs, particularly among low-income, racial and ethnic minority, and rural populations in the U.S. To help address these inequities, produce prescription programs are being implemented in many health care settings. However, key research gaps and programmatic barriers remain. In the proposed project, we will use research, education, and extension to improve nutrition security in rural underserved communities and deliver science-based knowledge to consumers, allowing them to make informed, practical decisions that can improve health equity. Our project goal is to implement and rigorously evaluate an innovative primary-care based healthy food prescription that is paired with incentives to use the local supermarket's established healthy food shelf-tag labeling system to increase healthy food choices at the point of purchase. We will: 1) assess the program's impact on participants' food and nutrition security, 2) assess the program's impact on participants' supermarket purchases and diet, and explore the program's impact on health, and 3) use the research findings to engage health systems, nutrition educators, and communities in evidence-based strategies to improve nutrition security. The program has the potential to sustainably encourage healthy food choices where decisions matter--in the supermarket, using existing supermarket resources. Improving purchasing patterns by increasing sales of less processed and whole foods, could also positively affect industry offerings and sustainability of the agricultural system as a whole.
Animal Health Component
100%
Research Effort Categories
Basic
(N/A)
Applied
100%
Developmental
(N/A)
Goals / Objectives
Long-term Goals: The proposed project will use research, education, and extension to improve nutrition security of rural underserved communities and deliver science-based knowledge to consumers, allowing them to make informed, practical decisions that can improve health equity. The project goal is to implement and rigorously evaluate an innovative healthy food prescription program, "Superstars," among low-income rural primary care patients, paired with an incentive to use a supermarket shelf-tag-labeling system that supports healthier choices at the point of purchase. Research findings will be used to engage health systems, nutrition educators, and consumers to improve nutrition security, population health, and health equity. We will: 1) assess the program's effect on participants' food and nutrition security, 2) assess the program's effect on the quality of participants' supermarket purchases and diet, and explore the program's effect on health, and 3) use the research findings to encourage health systems, nutrition educators and consumers to adopt evidence-based strategies that improve nutrition security, population health, and health equity.
Project Methods
Aims 1 and 2 Study Design: We will use a randomized controlled study design to test the effectiveness of the Superstars intervention among 500 low-income MaineHealth primary care patients who do most of their shopping at Hannaford Supermarket.Patients who meet the age and insurance eligibility criteria will be either provided a flyer about the program, called, or contacted by mail, or sent the equivalent information about the program through their MyHealth patient portal by MaineHealth administrators. If a patient indicates they are interested in participating in the study, they will be contacted by study staff who will assess remaining eligibility criteria: 1) Hannaford as the primary (> 50% of grocery purchases) weekly shopping venue and participating in the loyalty program for at least 6 months, 2) having ³ 2 visits recorded in the EHR in the past 2 years, 4) being ³ 21 years old, and 5) being enrolled or be willing to enroll in the MaineHealth electronic patient portal. Eligible patients who are interested in the program but have not yet enrolled in the patient portal will be provided with support from study staff via phone call to enroll.For eligible patients, study staff will obtain informed consent. Participants will then be sent a link to compete an enrollment (baseline) survey that includes questions about sociodemographic characteristics, outcome measures (nutrition security, food security) and other measures such as knowledge, attitudes, beliefs and skills related to nutrition, healthful shopping, food preparation, and depression. In addition, participants will be asked if they provide permission to access their MaineHealth electronic health record for blood pressure (BP) and body mass index (BMI).An exit survey, administered immediately post intervention, will include all questions on the enrollment survey except basic demographics. For intervention group participants, the exit survey will also include questions related to satisfaction with the intervention and any barriers to using the program that may have been experienced.We expect enrollment of 500 patients to take between 2 and 4 months and at least 95% (N=475) to actively use the loyalty program based on our experience conducting research in similar settings.25,26Randomization: We will use a randomized controlled study design to conduct our study with 500 participants from at least 5 MaineHealth primary practice sites in midcoast Maine. Once enrolled, half of the participants will be randomly assigned to receive the 4-month intervention while the other half will receive regular care.All participants will receive 1) a 5% discount on purchases from Hannaford Supermarkets if they use their loyalty program at check-out or for use shopping online through Hannaford.com (to allow purchase tracking) during the entire 4-month study period, and 2) information about how to access Hannaford Supermarkets nutrition resources available through the Hannaford Supermarkets website. These resources include recipes, and nutrition and cooking classes. Hannaford Supermarkets also have dieticians on staff as a resource for customers.Intervention Arm: In addition to the above discount and information, those in in the intervention arm will further receive a $40 monthly incentive to purchase 2- and 3-star products in any Hannaford Supermarket. Once enrolled, the primary care practice will send a healthy food prescription to intervention participants through the MyHealth patient portal. The prescription will focus on dietary guidance based on MyPlate and the Dietary Guidelines and will explain how participants can use the Guiding Stars to help them improve their diet and choose the incentivized items.The electronic discounts will be applied automatically at checkout or may be used shopping online through Hannaford.com when the loyalty program is used (shopper enters cell phone number or scans loyalty card at checkout). Participants will be sent reminders (via email or text, as preferred) by study staff to use their monthly 2- and 3-star incentive.Control Arm: Control arm participants will be provided regular care in addition to the 5% discount on all purchases from Hannaford Supermarkets each time they use their loyalty program at check-out and nutrition information, as described above.?Process: We will measure program implementation and process by tracking all activities related to identifying eligible patient populations, delivering the intervention, and using the incentive. Outcomes such as purchases and diet are influenced by nutrition-related knowledge, attitudes, beliefs and skills which will be measured at baseline and immediately post-intervention. Satisfaction with the intervention and the coupon redemption process will also be explored in the exit survey to help us understand how these project components may have influenced outcomes and to help refine recommendations for future implementation. Issues with 2-and 3-star voucher redemption at the supermarket could also influence outcomes.We will conduct at least 5 qualitative key informant interviews with Hannaford Supermarket staff (e.g., assistant manager or cashier), including 1 employee from each of the stores in communities linked to the healthcare sites. Trained study staff will schedule and conduct these interviews over Zoom during year 2 of the grant while the intervention is ongoing. Interview participants will receive $50 for their participation. The interviews will explore the process of providing the healthy food incentives and tracking participants for the purpose of the study in order to understand any barriers encountered by participant shoppers or by the retailer. Zoom calls will be recorded, transcribed, and analyzed using a rigorous thematic content analysis approach to enrich and expand our quantitative findings.128 For example, these interviews may provide a deeper understanding of how the store process worked and may yield detailed suggestions for specific process improvements for future implementation.Data collection and tracking systems will be put in place to capture process data which will be used to 1) make mid-term corrections on program implementation to ensure success; and 2) help explain outcome measures of success. These process measures, incorporated into each project component, will be used to assess fidelity of planned program implementation and assure the project stays on track for the duration of funding.The Framework for Program Evaluation in Public Health will guide our evaluation process through the outlined 6 steps: 1) engage key stakeholders along the way, 2) describe the program, 3) focus the evaluation design, 4) gather credible evidence, 5) justify conclusions, and 6) ensure use and share lessons learned. Program staff will monitor evaluation data in an ongoing way at regular project meetings. We will also schedule yearly meetings (and additional ad-hoc meetings, as needed) with the stakeholder advisory committee to interpret evaluation data and advise on making adjustments as needed. The analysis plan further elaborates how process evaluation will help to explain potential differences in research outcomes.