Prescription Produce for Food Insecure Veterans at Cardiometabolic Risk

About This Grant

Background: Food insecurity (FI), or the limited or uncertain availability of nutritionally adequate and safe foods, is common among Veteran households (approximately 1 in 4). FI worsens health across multiple dimensions, particularly for those with related diet-sensitive cardiometabolic conditions (e.g., diabetes). There is significant evidence that food security interventions that reduce cost related barriers to healthy eating, improve health related outcomes and patient satisfaction. Significance/Innovation and Impact: A prescription produce program (RxP) is an evidence-based food security intervention that subsidizes fruit and vegetable purchases. RxP improves food security, diet, and health outcomes (e.g., hbA1c, blood pressure, body mass index) and is being offered in VA and non-VA health care settings. however, there are evidence gaps related to RxP’s implementation. Specifically, RxP effectiveness is undermined by low levels of program fidelity (i.e., not using the full benefit as intended) and there is little existing research on implementation strategies that are hypothesized to improve RxP fidelity. There is opportunity to improve RxP fidelity within the unique VA service delivery environment where it may complement existing VA resources (e.g., MOVE!; diabetes self- management educational resources; nutrition counseling). Further, implementation of food security interventions, like RxP, is aligned with VHA strategic priority areas, HSR topic areas, and my proposed research and career goals advance Learning Health System Methods related to implementation science. Specific Aims: Aim 1 leverages administrative data on RxP fidelity and electronic health record data from Veteran participants from the largest RxP offered in the VA (n=3,140 Veteran households from the Durham VA Health Care System) to identify predictors of program fidelity. Aim 2 identifies RxP implementation barriers and facilitators and select and/or design strategies to improve RxP program fidelity, reach, and acceptability in real- world VA settings. Aim 3 is a feasibility pilot study of the enhanced RxP implementation strategies that are hypothesized to improve RxP fidelity in a food insecure Veteran population. These aims are guided by a conceptual model derived from the Chronic Care Model and the Health Equity Implementation Framework. Methodology: Aim 1 uses a regression tree machine learning methodology to identify factors, or combination of factors, that influence RxP program fidelity using data from the Durham VA RxP. Aim 2 collects qualitative data from a purposive sample of Veteran households with varying levels of fidelity based on Aim 1 findings that participated in the Durham VA RxP (n=~25) and collects qualitative data from clinicians/staff associated with implementation of RxPs at four VA Health Care Systems across the country (n=~15 from Durham VA; Maryland VA; Salt Lake City VA; Houston VA). I will use rapid-analysis qualitative research methods and engage with an advisory board as part of a five-step Implementation Mapping approach to identify RxP implementation barriers, facilitators, and strategies that are hypothesized to improve RxP fidelity, reach, and acceptability. Aim 3 tests the feasibility of implementation strategies developed in Aim 2 in a ~40 household randomized pilot study comparing an enhanced implementation approach designed in Aim 2 to RxP ‘implementation as usual’ based on existing best practices for offering an RxP. Paths to Translation/ Implementation: This application is based on two years of planning with operational and community partners, VA Food Security Office and Office of Health Equity’s ACORN initiative to ensure findings can support short- term, active RxP implementation efforts and long-term efforts to offer RxP as a sustainable food security benefit within the VA. IIR proposals will be submitted in years 3 and 5 test RxP implementation strategies. Findings will be shared in coordination with research collaborators, local operational partners (Whole Health; Ambulatory Care; Nutrition and Food Services), community partners, and VA national offices (VA Food Security Office and Office of Health Equity) to amplify dissemination and impact of findings.