1. Food Stamp Program: Emerging issues and research questions Economic Research Service FY 2008 Food Assistance and Nutrition Research Conference December 6, 2007 Washington, DC Barbara MkNelly, MS Cancer Prevention and Nutrition Section California Department of Public Health Public Health Institute

2. Emerging issues and research questions for how the Food Stamp Program could more effectively promote healthy eating California’s Healthy Food Purchase Pilot (Assembly Bill 2384, Leno) Network for a Healthy California - Food Stamp Nutrition Education (FSNE) Program

3. Healthy Food Purchase Pilot Program (Assembly Bill 2384 - Leno) Bill became law January ’07 but requires legislative appropriation for implementation. Develop a pilot program in not more than 7 counties that combines strategies that…. –Increase small grocers’ offerings of fruit and vegetables in low-income neighborhoods –Financial incentive to increase food stamp recipients’ purchase of fresh fruit and vegetables –Independent evaluation developed in consultation with USDA’s Economic Research Service (ERS)

4. Healthy Food Purchase Pilot Program Addresses Major Barriers

5. Financial Incentive: aka “Bonus Value Food Stamps” Food Stamp Program (FSP) consumers would receive additional FSP dollars based on the amount of their benefit spent on fresh fruits and vegetables. Example: Each FSP dollar spent on F & V would earn the FSP participant an additional 30 ¢ - 40 ¢ of FSP benefit on his or her EBT card.

6. Why bonus value? Incentive for healthy purchase rather than restrictions Uses Electronic Benefit Transfer (EBT) –Client and retailer oriented features Considerable interest in idea but has not been tested

7. Bonus Value operations research questions (1)—Economic Ideal bonus rate(s) to test – –retailers identified 30-40% Costing bonus approach –Amount currently being spent on fruit and vegetables –Increased demand stimulated by bonus Price elasticity literature Experimental literature

8. Bonus Value operations research questions (2)—Feasibility Programmatic features How would it work – different types of stores How best communicated to food stamp consumers Maximum/caps per transaction or household Systems implications –Retailer reimbursement system –Statewide automated welfare system (SAWS) consortium – 4 separate systems in the state

9. Evaluation Issues Formative research with food stamp recipients and retailers to inform design. Impact on food stamp recipients’ fruit and vegetable purchases: Data sources: possibly retailer data, food stamp recipients total food purchases Ideally, comparative impact of different strategies and bonus value amounts Issues: Institutional Review Board, informed consent, confidentiality Retailer and consumer satisfaction Programmatic/systems impact

10. Partnerships for Better Public Health

11. Food Stamp Nutrition Education (FSNE) in California Two programs both overseen by California Department of Social Services Food Stamp Program Network for a Healthy California –California Department of Public Health University of California, Davis

12. Public Health Perspective Social-Ecological Model

13. Network for a Healthy California Largest FSNE network in the nation ~ 150 local projects in 11 regions 3 targeted population campaigns: –Latino Campaign –African-American Campaign –Children’s Power Play! Campaign Retail and Worksite programs Providing FSNE at ~10,000 eligible sites – low- resource schools and pre-schools, food closets/pantries/banks, community clinics, low- income housing sites, grocery stores, worksites, festivals, health fairs, etc. Champions for Change multi-media campaign – TV, radio, outdoor, direct mail, website -

17. 14-minute DVD (English/Spanish) 24-page bilingual mini- magazine 9 bilingual Success Cards English and Spanish Reply Cards Fruit and vegetable Slide Guide Mailer to ~ 600,000 Low Income English and Spanish Speaking Households:

18. Institute of Medicine says… “USDA’s Food Stamp Nutrition Education (FSNE) program is an example of a federal innovation that encourages collaboration and that leverages resources. FSNE allows states to create social marketing networks, mobilize other organizations, and join efforts to conduct interventions with low-income participants to achieve healthier eating patterns and increased physical activity levels.” Institute of Medicine (2007) Progress in Preventing Childhood Obesity How Do We Measure Up?

19. Operational Question Q#1 What are the most effective targeting criteria for reaching FSNE eligible audience?

20. Targeting Successes and Challenges Examples of challenges for targeting –Majority of FSP recipients live outside FSNE eligible census tracts –Low income worksites – difficult to qualify –Media especially TV - difficult Recent successes for new sites –Food stamp office resource kit (video, informational stand) –Expanded criteria for retailer sites – $50k+ monthly food stamp redemptions

21. Evaluation Question Q#2: How to most effectively evaluate the combined efforts of local projects, targeted campaigns and media?

22. Network evaluation strategies Statewide surveillance with FSNE eligible people (needs comparison groups) Evaluation of branded interventions prior to roll-out Practitioner oriented impact evaluations –~50 local projects measure behaviors and behavioral determinants Importance of context: Robert Wood Johnson Foundation funded an expert review of Network’s evaluation system.

23. Institute of Medicine’s Child Obesity Prevention Framework

24. Policy Question Q#3: What potential exists for FSNE to work synergistically with other federal nutrition assistance programs to achieve better public health results?

25. Examples of Powerful Collaborations FSNE in schools supports healthy food offered in cafeteria and after school programs. FSNE alongside food banks’ fresh produce program has implications for USDA’s Emergency Food Assistance Program (TEFAP). FSNE and WIC promoting shared and reinforcing messages for example pertaining to new food package and educational materials/messages.

26. Conclusion Need to draw evidence from –Economics including consumer economics –Health education and behavior change theory –Advertising and marketing –Public health successes Potential for collaboration to address variety of types of barriers Urgency and public health implications require comprehensive, cross-cutting and coordinated strategies

27. For More on Interventions and Evaluation, Please Visit Us— For partners, professionals and links to campaigns, programs and resources — www.networkforahealthycalifornia.net New and growing! For parents and youth, in English and Spanish – www.cachampionsforchange.net Barbara.MkNelly@cdph.ca.gov