New York University
Food insecurity, that is, the lack of consistent access to nutritious and affordable food, is associated with poor diet, increased cardiovascular disease (CVD) risk, and has a negative long-term impact on the economy through increased health care costs. CVDs and food insecurity disproportionately affect Black and Hispanic families, and most of these racial health disparities can be attributed to social determinants of health, including poor access to healthy foods. A recent policy in the U.S. authorized the Supplemental Nutrition Assistance Program (SNAP) benefits to be used online to increase grocery access and promote healthy eating. Although online grocery shopping has been growing among populations of low-income, the selection of fruits, vegetables, and legumes (FVL), which are protective against CVD, is lower than in-store. Distrust of online hired shoppers' choices, fear of losing money on unsatisfactory purchases, and impulse of unhealthy food purchases have been the major barriers to online healthy food selection. Thus, there is a need for intervention packages that are effective, economical, and easily scalable into policies that address CVD-related outcomes and improve health equity. The proposed work will use a highly efficient methodological approach, the Multiphase Optimization Strategy (MOST), to test three experimental components aimed at barriers to online healthy food selection, called OPT-FRESH. This approach addresses weaknesses in prior studies, which cannot determine which elements of multicomponent interventions meaningfully improve outcomes. 360 families with children living in low-income urban communities of NYC will be randomized to receive some combination of the three experimental components for 12 weeks: 1) weekly text messages to improve the trust in online grocery services (off/on); 2) weekly match-up to $10 as a financial incentive for purchasing FVL online targeting loss aversion (off/on); 3) weekly instant shoppable grocery lists of culturally tailored meal suggestions using SNAP recipes targeted at impulse purchases (off/on). A monthly service fee waiver (3 in total), a monthly $5 stipend (3 in total), unlimited delivery fee waiver and a tutorial video addressing digital literacy will be constant components to promote equity in participant enrollment. Aim 1 will determine the combination(s) of the three experimental components that improve overall household FVL purchase and food insecurity (primary outcomes) and FVL intake of children (secondary outcome). Aim 2 will identify the optimized intervention that balances component(s) that are affordable and scalable (high adoption, implementation, maintenance) that still produce meaningful effects on the outcomes, using decision analysis for intervention value efficiency. Aim 3 will determine the mechanistic effects of the three intervention components on the outcomes using factorial mediation analysis. Working with community-based organizations and nutrition and hunger relief programs in NYC, a grocery delivery service, and a team with unparalleled expertise in experimental trials, policy, and MOST, we will implement optimized, affordable, and scalable intervention strategies to improve neighborhood food access and ultimately CVD outcomes in socially vulnerable families.
OPT-FRESH will use a highly efficient methodological approach for intervention development, the multiphase optimization strategy (MOST). We will partner with the private sector (Instacart) to leverage strategies from the public sector (SNAP) and test three experimental components aimed at barriers to online healthy food selection. The three experimental components, which were found in our pilot work to be feasible and acceptable, include: 1) weekly text messages to improve trust in online grocery services; 2) weekly match of up to $10 as a financial incentive for purchasing FVL online; and 3)…
Inclusion Criteria: * Adult (\> 21 years old) * Live in a household with a young child(ren) under the age of 10 years and above age 2. * Primary shopper for the household * Have access to a smartphone or computer to place online orders * Participation in the Supplemental Nutrition Assistance Program in the past year or income eligible (annual household income =\< 130% of the federal poverty line) * Agree to share itemized grocery receipts during the study (12 months) * Willing to order groceries online * English or Spanish speaker * Informed consent
At the onset of the intervention, all participants will receive tutorial videos via text, covering Instacart account setup, online item selection, and SNAP-eligible stores, aiming to improve digital literacy in grocery shopping. The video was developed by our team, reviewed by SNAP-Ed partners, and available in English and Spanish. Despite being considered helpful during the pilot, nearly half of the participants reported not receiving or watching the tutorial video. To address this, we will call all participants within the trial's first week to provide technical assistance, including step-by-step instructions on redemption of the free delivery membership. Phone follow-ups were well-received during the pilot. Also, an intervention package will be mailed to all participants as material to be referred to in the calls and throughout the intervention.
All participants will receive a 12-week Instacart+ Membership e-gift card, a monthly one-time use service fee waiver (3 in total) and a monthly one-time use $5 stipend (3 in total) eliminating the online delivery fee for orders \>$10.
Participants randomized to this component will receive 2 text messages weekly via EZ text to enhance their perception of behavioral control and trust in online grocery services. Text messages, deemed acceptable during our pilot, will be actionable, informed by constructs of the Theory of Planned Behavior, and tailored to assist shoppers using Instacart delivery services. We will deliver 24 short text messages (\<160 characters), on Friday afternoons and Mondays, each with one or more of the purposes rooted in behavior change techniques: increasing salience of the benefits of online grocery, modeling steps in behavior change, giving facts to address mistrust or improve control, asking questions to promote engagement, adding anonymized quotations from the pilot participants to reinforce social norms.
Participants randomized to this component (alone or in combination with another experimental condition) will receive $1 for each dollar spent on fresh, frozen, or canned FVL loaded onto Instacart Fresh Funds, verified based on the submitted online grocery receipt or data from Instacart. The incentive applies to online purchases only and will not be earned for in-store transactions. A maximum weekly matched incentive will be set to $10, following the local FV incentive NYC ("Get the Good Stuff"). Fresh Funds earned, supported by Instacart Health, is an infrastructure integrated with retailer payment systems. Incentives will only be used for purchases of healthier foods (FVL) predetermined by the research team, as it has been used by FV prescription programs.
Participants randomized to this component will receive weekly SNAP-Ed-based meal plans with instant shoppable grocery lists tailored to household size, dietary, and cultural preferences. All recipes will emphasize FVL-based eating patterns with Hispanic cuisine influences that have FVL as primary ingredients. Grocery lists organized by store department and recipe, will reflect the nearest available in-store unit. For example, if one recipe calls for 1 cup of flour, a small flour bag will be added to the list. Weekly meal plans will be shared via text as a photo and mailed as hard copies, with instant shoppable lists generated through Instacart's List feature as a hyperlink. Links to the instant shoppable list will be shared via text. Upon clicking, grocery items will be pre-filled automatically in the participant's online shopping cart. Participants can modify items and quantities before checking out.