The FRESH Study: The Fresh Bucks racial equity, socioeconomic & health outcomes study

ABSTRACT. Stark disparities in cardiometabolic health outcomes exist by racialized identity and income level. Low-income populations experience 40-70% higher risk for cardiovascular mortality compared to higher-income populations. Black and Latinx populations experience higher rates of at-risk cardiovascular profiles compared to White populations. Diet quality is hypothesized to play a key role in these disparities. But consuming a health- promoting diet is out of reach for many Americans, and disproportionately so for low-income populations and people of color. Structural and economic factors make high-quality diets out of reach for many. Specifically, the intersecting experience of food insecurity, poverty, structural racism, precarious employment, high cost, and difficult to access healthier foods creates a discriminatory and unjust context where accessing, purchasing, and eating a health-promoting diet, particularly one high in fruits and vegetables, is unattainable. As a result, interventions and policies that reduce these structural and economic barriers have high potential to improve food security, dietary quality, and ultimately improve health. To this end, the federal government, several states, and municipalities have introduced policy interventions that provide financial incentives to promote the purchase of fruits and vegetables by low-income populations. However, several prominent design features of these programs leave many of the structural causes of food insecurity and low fruit and vegetable consumption in place. In this study, we can improve what is known about the equity and impact of fruit and vegetable incentive programs through the study of Seattle's Fresh Bucks Program. This program has been designed with several features that have the potential to overcome the limitations of previous programs. Methodologically, we propose a mixed methods study that leverages randomized assignment for assessing causal impact, includes participatory approaches and a sequential explanatory mixed methods design to assess equity in implementation, and a quasi-experimental design to utilize electronic health records of program participants and a matched comparison population to estimate associations with long-term (2-4 years) program enrollment and health outcomes in the following Aims: 1) Determine the impact of Fresh Bucks on fruit and vegetable intake and food insecurity, leveraging randomized program assignment for causal impacts. 2) Assess Fresh Bucks implementation equity through redemption rates and experience. 3) Assess the impact of long-term access to Fresh Bucks on cardiometabolic health, including blood pressure and BMI, in a cohort of recipients and family members with matched electronic health records. Decreasing food insecurity and improving diet quality among low-income and minoritized populations is of primary importance for policymakers concerned about reducing systemic barriers to health. Upon completion of this work, we will have substantially advanced what is known about the dietary, health and implementation equity impacts of fruit and vegetable incentive programs and the potential for these policies to reduce systemic barriers to health.