How Does the Gus Schumacher Nutrition Incentive Program Work? A Theory of Change

Advancing Equity in the Farm Bill: Opportunities for the Gus Schumacher Nutrition Incentive Program (GusNIP)

The Gus Schumacher Nutrition Incentive Program (GusNIP) is a federally funded grant program that provides nutrition incentives-subsidies for purchasing fruits and vegetables (FV)-to Supplemental Nutrition Assistance Program (SNAP) participants. GusNIP currently advances nutrition equity by improving FV access for people with low incomes, yet inequities exist within GusNIP. We sought to identify inequities in GusNIP at the community, organization, partner, and individual levels and develop recommendations for farm bill provisions to make the program more equitable. In Spring 2021, a group of nutrition incentive experts (n = 11) from across the country convened to discuss opportunities to enhance equity in GusNIP. The iterative recommendation development process included feedback from key stakeholders (n = 15) and focus group participants with GusNIP lived experience (n = 12). Eleven recommendations to advance equity in GusNIP in the farm bill emerged across six categories: (1) increase total GusNIP funding, (2) increase funding and support to lower-resourced organizations and impacted communities, (3) eliminate the match requirement, (4) support statewide expansion, (5) expand and diversify retailer participation, and (6) expand program marketing. Including these recommendations in the upcoming and future farm bills would equitably expand GusNIP for SNAP participants, program grantees, and communities across the country.

Structural racism and geographic access to food retailers in the United States: A scoping review

This scoping review summarized findings and key measures from U.S.-based studies that 1) examined associations between geographic indicators of structural racism (e.g., redlining, racial segregation) and access to food retailers (e.g., supermarkets, convenience stores) or 2) documented disparities in access by neighborhood racial/ethnic composition. In 2022, relevant scientific literature was reviewed using Covidence software. Independent reviewers examined 13,069 citations; 163 citations advanced to the full-text review stage and 70 were selected for inclusion. Twenty-one studies (30%) linked one or more indicator of structural racism to food retailer access while 49 (70%) solely examined differences in access by neighborhood racial/ethnic composition. All studies featuring indicators of structural racism reported significant findings; however, indicators varied across studies making it difficult to make direct comparisons. Key indicators of structural racism in the food access literature included redlining (n = 3), gentrification (n = 3), and racial segregation (n = 4). Many U.S.-based studies have evaluated food retailer access by neighborhood racial/ethnic composition. Moving forward, studies should model indicators of structural racism and determine their influence on geographic access to large and small food retailers.

Client experience of food assistance programs among adults in the United States: a qualitative evidence synthesis protocol

Introduction

Policymakers, health practitioners, and other key partners are increasingly focused on ensuring that clients of food assistance programs have positive experiences, a key aspect of high-quality programming. The objectives of this review are to describe the experiences of clients participating in food assistance programs in the United States (US) and to identify ways that these programs promote or hinder positive experiences.

Methods and analysis

We will conduct a qualitative evidence synthesis with partners from food security organizations and community members. Peer-reviewed literature will be systematically searched in Scopus, CINAHL, and AGRICOLA. To identify grey literature, we will use Google's programmable search engine. This review will consider sources that present results of primary qualitative studies that focus on at least one food assistance program in the US and explore the perspectives of adult clients. Only sources published in English or Spanish from 2007 onward will be included. Multiple reviewers will screen articles for inclusion and extract data from articles that meet the inclusion criteria, using a structured data extraction tool. Thematic synthesis or meta-ethnography may be appropriate approaches for synthesizing the extracted data. The final selection of synthesis method will be determined once the set of primary qualitative studies to be included in the review is complete and the type of data presented in these studies is known. We will assess the methodological quality of the included studies using the CASP (Critical Appraisal Skills Programme) tool for qualitative studies and assess the confidence in the review findings using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach.

Discussion

The findings of this review will inform the development of measures to assess client experience and quality improvement efforts.

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education

OBJECTIVE

Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention.

DESIGN

Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later.

PARTICIPANTS

Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148).

INTERVENTION

Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis.

VARIABLES MEASURED

Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner.

ANALYSIS

Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence.

RESULTS

At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107).

CONCLUSIONS AND IMPLICATIONS

Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

How the Gus Schumacher Produce Prescription Program Works: An Adaptation of a Nutrition Incentive Theory of Change

The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports nutrition incentive (NI) and produce prescription programs (PPRs). PPRs allow healthcare providers to "prescribe" fruits and vegetables (FVs) to patients experiencing low income and/or chronic disease(s) and who screen positive for food insecurity. We developed a Theory of Change (TOC) that summarizes how and why PPRs work, identifies what the programs hope to achieve, and elucidates the causal pathways necessary to achieve their goals. We created the PPR TOC through an iterative, participatory process that adapted our previously developed GusNIP NI TOC. The participatory process involved food and nutrition security experts, healthcare providers, PPR implementors, and PPR evaluators reviewing the existing NI TOC and suggesting modifications to accurately reflect PPRs. The resulting TOC describes the mechanisms, assumptions, rationale, and underpinnings that lead to successful and equitable outcomes. Modifications of the NI TOC centered around equity and focused on inclusion of healthcare as an additional partner and the importance of health and healthcare utilization as outcomes. The TOC describes how the GusNIP PPR program reaches its goals. This understanding will be useful for PPR developers, implementers, funders, and evaluators for describing the pathways, assumptions, and foundations of successful PPRs.

Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis

BACKGROUND

It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause.   OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients.  SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification.

SELECTION CRITERIA

We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies.  DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach.  MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes.   AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.

Barriers and Facilitators to Implementation of a Child Care Center-Based Produce Delivery Program

BACKGROUND

Regular consumption of produce is a challenge for families with young children in low food access areas.

OBJECTIVE

A community partnership formed to evaluate feasibility of and interest in a child care center-based program for produce delivery from an online grocery vendor.

METHODS

Surveys were collected from caregivers across three child care centers, including produce program participants. Descriptive statistics summarize household characteristics and participants' experience with the program.

RESULTS

Challenges related to online payment and difficulty planning delivery times led to implementation of a modified intervention. Survey results revealed factors related to food access and storage that may impact interest and feasibility of online grocery in some communities.

CONCLUSIONS

Online grocery vendors may increase accessibility to fresh produce for families, but barriers to their use still exist. Trusted community partners such as child care centers may offer some of the resources needed for success.

Improving Fruit and Vegetable Accessibility, Purchasing, and Consumption to Advance Nutrition Security and Health Equity in the United States

In recent years, national and local efforts to improve diet and health in the United States have stressed the importance of nutrition security, which emphasizes consistent access to foods and beverages that promote health and prevent disease among all individuals. At the core of this endeavor is fruit and vegetable (FV) consumption, a dietary practice that is integral to attaining and sustaining a healthy diet. Unfortunately, significant inequities in FV accessibility, purchasing, and consumption exist, particularly among populations that are socially and economically disadvantaged. To achieve nutrition and health equity in the United States, the field must center the goal of nutrition security and initiatives that aim to increase FV consumption, specifically, in future work. The International Journal of Environmental Research and Public Health (IJERPH) Special Issue titled "Nutrition and Health Equity: Revisiting the Importance of Fruit and Vegetable Availability, Purchasing, and Consumption" features several scholarly publications from experts conducting timely research on these topics. In this commentary, we (1) summarize the U.S.-based literature on inequities in FV accessibility, purchasing, and consumption, (2) describe how the contributions to this IJERPH special issue can advance nutrition security and health equity, and (3) outline future research questions from our perspective.