Intervention Study of Cost-Offset Community Supported Agriculture (CO-CSA)

Community Supported Agriculture (CSA) is an innovative approach to increasing consumer access
to and consumption of fresh produce, thereby lowering obesity prevalence. However, CSA
"share" costs may be a barrier for low-income households with children. This multistate study
examines whether subsidizing the cost of CSAs, integrated with tailored education: 1)
increases consumption of fruits and vegetables, 2) substitutes fruits and vegetables for more
energy-dense foods, and 3) improves overall diet quality and energy balance, thus helping
children maintain healthy body weights. It also investigates how cost-offset CSAs ("CO-CSAs")
contribute to local agricultural economies. Given the well-documented risk for obesity and
limited access to fresh produce among low-income individuals, those households are the target
of the intervention in four geographically-diverse states: Vermont, New York, North Carolina
and Washington.

FORMATIVE AND LONGITUDINAL RESEARCH: Qualitative and quantitative research is being used to
inform implementation of the randomized trial, refine outcome assessment strategies, and
provide information needed to design a tailored curriculum to enhance low-income households'
knowledge, skills, attitudes, and behaviors related to the use of CSA produce and healthy
eating.

In the first year of the study, the investigators conducted interviews and focus groups with
stakeholders to gather in-depth data related to the potential of CO-CSA operations to meet
the needs and preferences of low-income households and the types of information that would be
most valuable to include in the study's curriculum. Key stakeholder groups included adults
and children from low-income households, CSA farmers, current full-paying CSA members, and
nutrition educators.

The investigators also are conducting a longitudinal quantitative examination of dietary
behaviors among current CO-CSA participants in an existing statewide program in Vermont.
Using online surveys, the investigators are measuring dietary outcomes quarterly among
children, and biannually among adults, from low-income households in the program. Data from
Year 1 was used to inform the intervention, while data from subsequent time points will
provide an opportunity for analysis of longitudinal patterns.

RANDOMIZED INTERVENTION: In the second phase of the project, the investigators will implement
and evaluate a three-year delayed intervention randomized controlled trial of CO-CSA plus
skill-based, CSA-tailored education in the four states. The investigators will compare
changes in dietary behaviors, reported consumption, energy intake, and weight status
parameters between children aged 2-12 in 120 control and 120 intervention households. Two
hundred households were enrolled in 2016 and an additional 40 households will be enrolled in
2017. Participant households enrolled in 2016 will receive a CO-CSA share for two seasons and
education during their first CO-CSA season (Y1 for intervention households and Y2 for control
households). Households enrolled in 2017 will receive a CO-CSA share and education for one
season (Y2 for intervention households and Y3 for control households). In addition to
outcomes with participants, investigators will conduct economic analysis to evaluate the
impact of CO-CSA for farms and communities. While these analyses are not related to the human
participants, they are central to the overall project goals.

Inclusion Criteria:

- English-speaking

- Parent or legal guardian of a child in the household between the ages of two and 12
years

- Self-reported income less than 185% of the Federal Poverty Level or report enrollment
in SNAP, WIC, or Head Start

- Has access to a computer from which s/he can complete on-line data collection

- Has an active e-mail account or willing to create an e-mail account

- Has not participated in CSA in the past three years

- Willing to purchase the 50% CO-CSA share (can use SNAP benefits if desired and
available)

- Willing to attend CSA-tailored education sessions

- Willing to make a firm commitment to three years of participation (2016 enrollment) or
two years of participation (2017 enrollment), with timing of the off-set benefit
determined by randomization

- Complete baseline survey

- Pay deposit to farm

Exclusion Criteria:

- Non-English-speaking

- Not the parent or legal guardian of a child in the household between the ages of two
and 12 years

- Self-reported income equal to or greater than 185% of the Federal Poverty Level and no
report of SNAP, WIC, or Head Start enrollment

- Does not have access to a computer from which s/he can complete on-line data
collection

- Does not have an active e-mail account or is not able or willing to create an e-mail
account

- Has participated in CSA in the past three years

- Not able or willing to purchase the 50% CO-CSA share

- Not able or willing to attend CSA-tailored education sessions

- Not able or willing to make a firm commitment to three years of participation (for
2016 enrollment) or two years of participation (2017 enrollment), with timing of the
off-set benefit determined by randomization

- Not able or willing to complete baseline survey

- Not able or willing to pay deposit to farm