Recipient Organization
UNIV OF MARYLAND
(N/A)
COLLEGE PARK,MD 20742
Performing Department
(N/A)
Non Technical Summary
Consuming a diet rich in fruits and vegetables (FV) is associated with lower risks of mortality and morbidity related to diet-related illnesses. However, a vast majority of the US population does not meet the daily recommended intake of FV, with the lowest intake observed in individuals living in poverty.The project goal is to establish, implement, and evaluate a community-led produce prescription program that improves diet-related health outcomes and food security by increasing locally sourced FV consumption. Utilizing a multi-faceted and collaborative approach, we aim to construct a successful and sustainable produce prescription model. Additionally, the project will support local farmers, fostering a more resilient and economically sustainable local food system, supporting rural America.Objectives: a) Develop a referral network (e.g., local food producers/distributors, healthcare providers, extension educators) and enroll 140 food-insecure individuals from two Maryland counties selected due to a higher rate of food insecurity, and higher prevalence of diet-related illness. b) Implement a community-driven produce prescription program. Components will include: a 6-week EFNEP nutrition education, prescribed, locally grown weekly FV delivery, and monthly tele-counseling for 24 weeks. Evaluate the effectiveness of the program on FV intake, psychosocial factors related to FV consumption, food insecurity, and clinical outcomes.By employing evidence-based research methodologies and partnering with the Extension system, healthcare providers, and community partners, our program aims to create sustainable and impactful transformations for individuals experiencing food insecurity while bolstering local food systems. Our program can serve as a replicable model in similar settings.
Animal Health Component
(N/A)
Research Effort Categories
Basic
(N/A)
Applied
(N/A)
Developmental
(N/A)
Goals / Objectives
The program goal is to establish, implement, and evaluate a community-led produce prescription program that improves diet-related health outcomes and food security by increasing locally sourced FV consumption in the target counties in MD. It will utilize evidence-based research methodologies, the Extension system, and collaboration with healthcare providers and community partners to build a successful and sustainable model. The program will also support local farmers, fostering a more resilient and equitable local food system.To achieve the program goal, a single-group pre- and post-study design will be used to assess effectiveness. Participating healthcare partners will screen and refer potential participants to the team, and a total of 140 eligible food-insecure individuals who suffer from or are at risk of developing hypertension, type II diabetes, and/or obesity will be recruited. The intervention will consist of 1) a 6-week EFNEP nutrition education; 2) prescribed, culturally sensitive, and locally-grown weekly produce delivery (~ 12 lb of local produce) for 24 weeks through a partnership with CFS3) monthly nutrition tele-counseling support by trained dietetic students for 24 weeks.Through collaboration with key community stakeholders and the use of evidence-based strategies, this project will address health challenges and empower food-insecure community residents to prioritize their well-being. Additionally, the program will explore methods to integrate the program into existing healthcare systems, creating a sustainable and scalable model for replication.Objectives: Objective 1: Develop and implement a community-driven produce prescription program composed of EFNEP education, produce prescription, weekly fresh produce delivery, and monthly tele-counseling support by partnering with the extension system, community stakeholders, and a higher education system.Objective 2: Evaluate the effectiveness of the program in improving FV consumption, food insecurity, and health outcomes related to hypertension, type II diabetes, and obesity, and whether the program effectiveness differs according to moderating variables such as race and gender.Hypothesis 2-1: Participants will have better clinical outcomes (blood pressure control, HbA1c, and reductions in blood pressure levels) compared to baseline.Hypothesis 2-2: Participants will have significantly improved FV consumption and food insecurity status compared to baseline.Hypothesis 2-3: Participants will have significantly improved self-efficacy, perceived diet quality, nutrition knowledge, and readiness to eat more FV compared to baseline.Objective 3: Examine the process and outcome measures of the program to determine its effectiveness, potential for sustainability, and usefulness of an expansion in the future.
Project Methods
Using a single-group pre- and post-design, which is a more viable option for this community-based participatory program, the effect of the proposed approach will be tested. This study will have planning, implementation, and program expansion/ sustainability phases.1) Planning phase: Using a CBPR framework, a Community Advisory Board comprising stakeholders, including representatives of the target participants from various sectors, will be involved in the program to ensure shared ownership. Key planning activities include finalizing logistics, materials, protocols, staff training, and submission and approval of the IRB application.2) Implementation phase primarily focuses on participant recruitment, program implementation (including nutrition education, produce prescriptions, and monthly tele-counseling), and evaluation of the program process and effectiveness. Detailed information on program implementation can be found in the sampling, intervention, and evaluation sections.3) Sustainability phase: The team will discuss program expansion and long-term sustainability, focusing on identifying sustainable components and strategies for building coalitions with stakeholders to support the program's success.Sampling methodsTo recruit eligible participants efficiently, collaboration with healthcare partners and implementation of a streamlined two-step process minimizes the burden on clinic staff.Identification and initial screening During routine clinic visits, adult patients will undergo a brief screener at check-in to assess eligibility. This includes a 2-item Hunger Vital Sign32 to evaluate food insecurity and questions related to diet-related illnesses and health conditions such as hypertension and type II diabetes. Trained clinical staff will conduct the screening. Healthcare providers may also refer potential participants to the program based on their assessment. Interested patients will proceed to the verification phase, and program information will be made available through flyers and posters at participating clinics.Referral and eligibility verification After the initial screening, potential participants will be referred to the UMD project staff for verification. This process will follow a standardized study protocol and be conducted via phone to confirm eligibility. Inclusion criteria include (1) being 18 years or older, (2) regularly using participating healthcare clinics, (3) experiencing food insecurity, (4) residing in the target counties, and (5) meeting specific health criteria (e.g., having systolic blood pressure of 130-170 mm Hg and/or diastolic blood pressure of 80-100 mm Hg or on hypertension medication, or has HbA1c ≥ 6.5%, or BMI ≥ 30). Exclusion criteria consist of having acute or terminal conditions, psychiatric diagnoses precluding participation, or extreme weight categories. Once eligibility is confirmed, participants will receive a Qualtrics link via email to complete a baseline survey. As compensation, participants will receive a $20 stipend upon survey completion.Intervention designThe intervention program consists of a 6-week EFNEP nutrition education, prescribed weekly local FV boxes for 24 weeks, and monthly tele-nutrition counseling for 24 weeks. These components, along with factors such as class attendance and adherence to the provided FV, will be considered for dose-response analysis to better understand the impact of the intervention. More details on the key intervention approaches are provided in the following sections.1) EFNEP Nutrition Education (Eating Smart Being Active)Participants will attend a series of six group educational sessions, with each session lasting between 1.5 and 2 hours. The evidence-based "Eating Smart Being Active" curriculum will be used. It normally consists of nine lessons; however, for this study, it is condensed into a shortened version with six lessons. This curriculum is designed to be delivered by paraprofessionals and covers important topics including nutrition, physical activity, self-management, food labels, goal setting, portion size, and recipes.2) Produce prescriptionCFS partners with local farmers in the target counties to deliver fresh produce and support food-insecure families. To promote a resilient and sustainable food system, CFS will provide a weekly FV box containing approximately 12 lbs. of seasonal produce, valued at $30.Participants can pick up fresh produce at mobile farm markets within their communities or have boxes conveniently delivered to locations where they attend nutrition education sessions - or to their homes if needed. To minimize transportation costs and food mileage, if necessary, the project team will explore grouping participants by address and establishing a centralized pick-up location for the weekly produce boxes. Localized pick-up sites offer additional benefits, such as reducing carbon emissions, supporting local farmers, and fostering community interaction and resource exchange.3) Monthly nutrition tele-counseling support by dietetic studentsDietetic students, trained by the University Health Center to provide peer nutrition coaching, will provide interactive tele-counseling support for project participants. Before each monthly phone call, the dietetic students will review the participants' goals related to diet and physical activity, developed during the 6-week nutrition education sessions, and during the call, they will discuss progress, dietary habits, and barriers, and provide positive reinforcement. This provides participants with personalized support and allows dietetic students to develop their skills in working with diverse patients.EvaluationThe evaluation plan includes process and impact evaluations at participant and firm levels. It meets the requirements of the GusNIP Comprehensive Program Evaluation and goes beyond by incorporating key psychosocial determinants and conducting a comprehensive process evaluation. Validated measures will be used to assess the program's impact on various diet-related illnesses. Process evaluation measures will also be utilized to evaluate reach and fidelity, enabling the monitoring and enhancement of program delivery and community adoption. A thorough evaluation will determine the intervention's effectiveness and identify necessary improvements for greater impact.1) Process evaluation will assess dose (class attendance), fidelity (coverage of nutrition education topics), and operationality (partner interviews) to document program implementation. Process data will also include tracking produce types and volumes in the weekly bags.2) Outcome evaluation "Extended" participant-level core metrics.Required participant-level core metrics, including a dietary screener questionnaire and food security questions, will be collected to assess the impact of the program on FV consumption and food insecurity. An extended survey will also measure psychosocial constructs related to FV consumption, including self-efficacy, perceived benefits, and readiness to consume FV and self-care behaviors for diet-related illness.Clinical Outcomes. Collaboration with healthcare partners will support the collection of clinical outcomes of participants, including blood pressure, HbA1c, lipid profiles, and anthropometrics. MobileMed, for example, utilizes the ClinicalWork system for all patient encounters and clinic visits. With patient consent, IRB approval, and appropriate data use agreements, participants' clinical data will be available.Adult EFNEP pre- and post surveys will also be administered before and after the 6-week period of nutrition education to measure behavior change in diet and physical activity.