Designing Food Voucher Programs to Reduce Disparities in Healthy Diets

摘要 通过增加食物和蔬菜(F&V)消费来改善饮食，显著降低患车祸的风险 心血管疾病(CVD)。在低收入人群中提高F&V的可及性和可负担性的计划 美国人一直受到与贫困相关的食品消费循环的阻碍：倾向于 在每月初收到资金后不久就过度消耗卡路里，耗尽了 餐饮采购，或所有食品采购，在月底之前。仅仅增加粮食援助资金并不能 解决这个问题，但一项关于饮食行为的新兴理论表明，为食物提供资金 在整个月内分发较小的分期付款将使消费周期平稳并改善 健康饮食--抵消对一次性、每月一次的分期付款的反应倾向 收到资金后立即购买高卡路里食物。该理论还表明，资金-TAR- 获得特定的健康食品(例如，F&V)将比无针对性的资金更多地改善饮食，尽管在- 利用定向资金的便利性。我们的初步数据支持这两个假设，我们将严格- 通过比较提供食品购物券的其他方法，在现实环境中进行严格的测试。 我们已经建立并测试了基础设施，以提供所有主要食品店接受的代金券(例如， 超市、街角商店)在两个低收入社区。利用这一创新基础设施， 目的1我们提出了一项随机试验，采用2×2析因设计，比较20美元的有效代金券 一个月至四张5美元代金券，每张有效期为每月的连续一周(一次性支付与分发 资金)，并将仅限于F&V购买的代金券与可兑换任何食品的代金券进行比较(目标 与非定向资金的对比)。通过我们的社区合作伙伴招募的低收入成年人(N=288)将- 受制于四种为期6个月的干预措施之一：每月定向干预、每月非定向干预、每周定向干预或每周干预 我的无目标优惠券。参与者将通过有效的口头24小时饮食召回进行评估 在低识字率人群中，确定F&V的日常消耗量和总体饮食质量的指标 第0个月、第6个月和第12个月(凭证结束后6个月)。其他调查将确定主持人和调解人 改善饮食的方法。在目标2中，我们将计算代金券计划的成本效益。凭单 以及其他支持健康饮食的干预措施减少了人群水平的心血管疾病差距 几十年。因此，不可能直接观察这种干预措施的全部成本和收益。 有时间限制的试验。根据最近的NIH政策声明，我们将通过应用INNO-INNO来克服这个问题- 创新的、有效的微观仿真建模方法--一种集成试验结果的系统科学方法 有关于饮食变化对一生中心血管疾病风险和成本影响的全面数据。我们会 确定哪些代金券交付策略经济高效地减少CVD差异-解决关键的科学问题 健康饮食干预研究中的不确定性。

Abstract Improving diets through increased food and vegetable (F&V) consumption significantly reduces the risk of car- diovascular disease (CVD). Programs increasing the accessibility and affordability of F&Vs among low-income Americans have been hindered by the food consumption cycle associated with poverty: the tendency to over-consume calories shortly after receiving funds at the beginning of each month, draining the budget for F&V purchases, or for all food purchases, by month's end. Increasing food assistance funding alone does not resolve this problem, but an emerging theory about dietary behavior suggests that providing funds for food in smaller installments distributed throughout the month will smooth the consumption cycle and improve healthy eating—counteracting the tendency to respond to lump sum, once-monthly funding installments by purchasing calorie-dense foods immediately after funds are received. The theory also suggests that funds tar- geted toward specific healthy foods (e.g., F&Vs) will improve diets more than untargeted funds, despite the in- convenience of utilizing targeted funds. Our preliminary data support both hypotheses, which we will rigor- ously test in a real-world setting by comparing alternative approaches for delivering food purchasing vouchers. We have established and tested the infrastructure to provide vouchers accepted by all major food stores (e.g., supermarkets, corner shops) in two low-income neighborhoods. Leveraging this innovative infrastructure, in Aim 1 we propose a randomized trial with a two-by-two factorial design, comparing $20 of vouchers valid for one month to four $5 vouchers each valid for a sequential week of the month (lump sum versus distributed funding), and comparing vouchers restricted to F&V purchases to vouchers redeemable for any food (targeted versus untargeted funding). Low-income adults (N=288) recruited through our community partners will be ran- domized to one of four 6-month interventions: monthly targeted, monthly untargeted, weekly targeted, or week- ly untargeted vouchers. Participants will be assessed through efficient verbal 24-hour dietary recalls validated among low-literacy populations, to determine daily consumption of F&Vs and metrics of overall dietary quality at months 0, 6 and 12 (6 months after vouchers end). Additional surveys will identify moderators and mediators of dietary improvement. In Aim 2, we will calculate the cost-effectiveness of the voucher programs. Vouchers and other interventions that support healthy diets reduce population-level CVD disparities over the course of decades. Hence, the full costs and benefits of such interventions are not possible to directly observe through time-limited trials. Following recent NIH policy statements, we will overcome this problem by applying an inno- vative, validated microsimulation modeling approach—a systems science method that integrates trial results with comprehensive data on the effect of dietary changes on CVD risks and costs over the life course. We will identify which voucher delivery strategies cost-effectively reduce CVD disparities—addressing a key scientific uncertainty in healthy eating intervention research.