to Serve Medically Underserved Georgians February 6, 2019 ASNNA February 6, 2019 Feasibility of SNAP-Ed Implementation Models Promoting Community-Clinical Linkages to Serve Medically Underserved Georgians Jung Sun Lee, PhD, RDN| Professor, Principal Investigator Edda Cotto-Rivera, MPH, CHES®| Project Coordinator Sarah Stotz, PhD, RD, CDE, LD| Research Associate Nicholas Slagel, MS| Graduate Research Assistant University of Georgia Supplemental Nutrition Assistance Program Education (UGA SNAP-Ed) 20 min presentation

Outline UGA SNAP-Ed Overview UGA SNAP-Ed Programs February 6, 2019 Outline UGA SNAP-Ed Overview UGA SNAP-Ed Programs UGA SNAP-Ed and Clinical Collaborations Partnership building process Key features of the implementation models Process and resources needed to implement and evaluation the models Opportunities for Collaboration

February 6, 2019 UGA SNAP-Ed | Overview Funded by USDA SNAP-Ed Nutrition Education and Obesity Prevention Grant Program since 2013 One of the four SNAP-Ed Implementing Agencies in Georgia Provides innovative evidence-based, culturally appropriate nutrition education and obesity prevention interventions for low-income Georgians Based on collective capacity of UGA, infrastructure and network of the UGA Cooperative Extension, and collaboration with diverse stakeholders and communities across the state 3

UGA SNAP-Ed | Programming February 6, 2019 UGA SNAP-Ed | Programming Dissemination and Implementation Model Using approaches to best communicate and spread nutrition education and obesity prevention to target audiences Information Communication channels Context Perceived values, preferences, beliefs Systematic Evaluation Employing more rigorous and innovative evaluation methods following the USDA SNAP-Ed Guidance and the SNAP-Ed Evaluation Framework Ongoing integrated series of evaluation activities Using interdisciplinary mixed research methods Appropriate outcome measures

Social Marketing Food Talk February 6, 2019 UGA SNAP-Ed | Programs UGA SNAP Ed Food Talk Direct Nutrition Education (Food TalK, Food Talk: Better U, and Food Talk: Farmers Market curricula) 8 counties Food eTalk Innovative, mobile- friendly Online eLearning Nutrition Education All 159 counties Social Marketing Food Talk eNewsletters, social media, and FNV campaigns Healthy Child Care Georgia Child Care/ECE Nutrition Education Clarke county

Food Talk: Farmers Market February 6, 2019 UGA SNAP-Ed Direct Education | Three Culturally Tailored Curricula Food Talk Food Talk: Better U Food Talk: Farmers Market Adapted from UGA EFNEP Food Talk Six 60 minute sessions Based on DASH diet principles Cooking demonstrations Recipe sampling Educational extenders Based on comprehensive needs assessment on healthy weight management Four 90 minute sessions Based on obesity prevention and DPP principles Interactive format including sharing session, goal setting, homework, and physical activity Based on Food Talk and needs assessment Eight 30 minute standalone sessions offered at farmers market settings Vegetable centric recipes Lessons on calcium & protein

UGA SNAP-Ed eLearning| Food eTalk and Food eTalk: Better U February 6, 2019 UGA SNAP-Ed eLearning| Food eTalk and Food eTalk: Better U Content based on validated UGA SNAP-Ed curricula Two comprehensive programs Food eTalk Food eTalk: Better U 6 Lessons 8-12 minute/lesson with additional cooking videos 4 ‘just in time’ videos DASH diet principles 4 Lessons 2-3 minute/lesson Cooking videos, exercise videos, ‘just in time’ videos DPP principles

UGA SNAP-Ed Community and Clinical Partnerships February 6, 2019 UGA SNAP-Ed Community and Clinical Partnerships UGA SNAP-Ed’s statewide dissemination/implementation models strive to 1) reach and impact the nutritional health of underserved vulnerable Georgians and 2) inform the design and conduct of effective and efficient nutrition education and obesity prevention in various community and clinical settings in Georgia Through the existing infrastructure and network of UGA Cooperative Extension and safety net clinic networks, UGA SNAP-Ed has been offering nutrition education to serve medically underserved Georgian adults in counties with or without direct nutrition education opportunities and resources

UGA SNAP-Ed Community and Clinical Linkage Programs February 6, 2019 UGA SNAP-Ed Community and Clinical Linkage Programs To provide SNAP-Ed eLearning program among low-income patients at safety net clinics UGA SNAP-Ed eLearning Safety Net Clinic Project Athens, GA (Since 2016) To provide SNAP-Ed eLearning program and supplemental Georgia-grown produce at safety net clinics Safety Net Clinic Project Valdosta, GA (Sep, 2017-Jun, 2018) To provide SNAP-Ed direct education program, produce incentive, and health screening at safety net clinics UGA SNAP-Ed Fruit and Vegetable Prescription (FVRx®) Program Athens, GA (Jul, 2017-Dec, 2018)

Safety Net Clinic Project February 6, 2019 UGA SNAP-Ed eLearning Safety Net Clinic Project Athens, GA (Since 2016) UGA SNAP-Ed Community and Clinical Linkage Programs Mercy Health Center: Safety net clinic in Athens, GA serving ~10,000 low-income patients/year Intervention: Ongoing UGA SNAP-Ed eLearning program Target Audience: New patients Evaluation: Qualtrics survey using retrospective pre-test design Assess users’ change in self-efficacy and intention to follow specific healthy eating and physical activity practices: ST1 (a, b, m, l), ST2 (a, b, d, e2, e3), ST3 (a), MT11 (d, e) UGA IRB approved the protocol Low-income Patients Mercy Health Center Kaiser Foundation UGA Cooperative Extension UGA SNAP-Ed Georgia Health Foundation

Safety Net Clinic Project February 6, 2019 UGA SNAP-Ed eLearning Safety Net Clinic Project Athens, GA (Since 2016) UGA SNAP-Ed Community and Clinical Linkage Programs UGA SNAP-Ed provides technical support and unique access to our online eLearning program to clinic patients

UGA SNAP-Ed Community and Clinical Linkage Programs February 6, 2019 UGA SNAP-Ed eLearning Safety Net Clinic Project Valdosta, GA (Sep, 2017-Jun, 2018) UGA SNAP-Ed Community and Clinical Linkage Programs Partnership Health Center: Safety net clinic in Valdosta, GA serving ~5,700 low-income patients/year Intervention: 12 week UGA SNAP-Ed eLearning program and supplemental weekly free produce Target Audience: SNAP-Ed eligible adults with at least one diet-related chronic condition Evaluation: Non-randomized control study design with mixed methodology; Key SNAP-Ed outcome indicators (ST1, ST2, MT1, MT2, and MT3) Quantitative: Self-reported 24-hour dietary recall; food insecurity; pre- and post-measurements on anthropometrics and biometrics Qualitative: pre- and post-focus groups with participants; individual interviews with key stakeholders UGA IRB approved the protocol Low-income Patients Partnership Health Center Local Farmer UGA Cooperative Extension UGA SNAP-Ed UGA CTRU/ UGA CAES

UGA SNAP-Ed Community and Clinical Linkage Programs February 6, 2019 UGA SNAP-Ed eLearning Safety Net Clinic Project Valdosta, GA (Sep, 2017-Jun, 2018) UGA SNAP-Ed Community and Clinical Linkage Programs Supplemental Locally-Grown Produce Provided from a local farmer identified through Lowndes County Extension Office Intention to provide seasonal, locally-grown supplemental produce Box size varied depending on number of members in a family Farmer delivered to the clinic on Tuesday mornings for 12 weeks, participants picked up from the clinic that day

UGA SNAP-Ed FVRx® Program February 6, 2019 UGA SNAP-Ed FVRx® Program Athens, GA (Jul, 2017-Dec, 2018) UGA SNAP-Ed Community and Clinical Linkage Programs Athens Nurses Clinic: Safety net clinic in Athens, GA serving ~1,200 low-income patients/year Intervention: A six month FVRx program including UGA SNAP-Ed direct education, produce prescription, and monthly health screening Target Audience: SNAP-eligible adults with at least one diet-related chronic condition Evaluation: Non-randomized control study design with mixed methodology; SNAP-Ed outcome indicators (ST1, ST2, MT1, MT2, and MT3) Quantitative: Self-reported 24-hour dietary recall; food insecurity; food purchasing practices; pre- and post-measurements on anthropometrics and biometrics Qualitative: pre- and post-focus groups with participants UGA IRB approved the protocol Low-income Patients Athens Nurses Clinic Athens Farmers Market Pinewood Community UGA Office of Sustainability UGA Cooperative Extension UGA SNAP-Ed Wholesome Wave GA/ Piedmont Foundation

UGA SNAP-Ed FVRx® Program February 6, 2019 UGA SNAP-Ed FVRx® Program Athens, GA (Jul, 2017-Dec, 2018) UGA SNAP-Ed Community and Clinical Linkage Programs Multi-level Intervention Individual level: nutrition education Interpersonal level: community coordinator Setting level: farmers market Sector level: provider generated produce prescription Produce Prescription Direct subsidy as supplemental income $1/day per household member

UGA SNAP-Ed Community and Clinical Linkage Programs| Process February 6, 2019 UGA SNAP-Ed Community and Clinical Linkage Programs| Process Needs assessment Identify Interested community and clinical partners Establish partnerships: - MOUs - Resources (funding, personnel, facilities, etc.) Program planning Program implementation Program evaluation Valdosta Project 11/2017 12/2017 2/2018 5/2018 8/2018

UGA SNAP-Ed Community and Clinical Linkage Programs| Findings February 6, 2019 UGA SNAP-Ed Community and Clinical Linkage Programs| Findings UGA SNAP-Ed implementation model based on community and clinical partnerships is feasible and sustainable with appropriate planning and support Building collective capacity among existing community-based key stakeholder organization resources Balancing resource utilization and workload among the key organization stakeholders Structuring the program to sustain participant engagement and enhance motivation       17

“Also just Ag been doing what we're supposed to do, be a resource for ag education. We're going to be educating them on where their fruit and vegetables coming from, and also connecting them with the source to where they can get fresh produce if they want some.” (UGA Extension representative) “It’s like, the produce grown down the street could be sold right here at the clinic where the patients come anyway, and I think the Extension office – it’s right down the road – not even far.” (Safety net clinic representative) “Our ultimate goal is to translate science to healthcare, but also do community outreach is just as important and community education. Doing a project like this shows how nutrition and healthcare are so closely tied together, and how they rely on one another, and how it can improve or affect a community for the better outcome.” (UGA CTRU representative)

UGA SNAP-Ed Community and Clinical Partnership Programs| February 6, 2019 UGA SNAP-Ed Community and Clinical Partnership Programs| Implications Continue to build collective capacity among medically underserved GA communities, UGA SNAP-Ed, UGA Cooperative Extension, GA CTSA, and healthcare systems Understand strategies to harness existing resources and expertise of key partners to design, implement, and evaluate community-based programs Explore sustainable solutions to reduce food insecurity and nutritional health disparities in underserved populations Imperative for SNAP-Ed implementing agencies to continue innovative programming and rigorous evaluation to assure the development and delivery of evidence-based nutrition education and obesity prevention programs Proved potential to

Jung Sun Lee, PhD, RDN | Principal Investigator| leejs@uga.edu February 6, 2019 Thank you! Any questions? Jung Sun Lee, PhD, RDN | Principal Investigator| leejs@uga.edu Edda Z. Cotto-Rivera, MPH, CHES® | Project Coordinator | ecrivera@uga.edu University of Georgia Supplemental Nutrition Assistance Program Education (UGA SNAP-Ed) Funded by USDA SNAP-Ed Grant, Kaiser Foundation, Georgia Health Foundation, Wholesome Wave GA, Piedmont Foundation, Georgia CTSA Seed Grant (UL1TR002378), UGA CAES Seed Grant, and UGA Office of Sustainability