Larisa Gearhart

During the course of this fellowship, the natural unfurling of a research project has ensued. Scientific progress is built on failure; learning to handle failures is a part of scientific life. Learning to be flexible as projects change course is also imperative as a community health scientist. I have learned valuable lessons from this project, but see clear next steps and ways to improve analyses in the future which can be of further help to the organization and the community it serves.

Lessons Learned

I am driven towards helping those who find themselves in situations similar to my own. Those with chronic diseases, in low-income situations, and part of minority communities are particularly near and dear to my heart, so this project working with low-income, minority, food insecure patient data was a natural calling. But it is challenging to come into a project with enthusiasm and think you will be able to run certain analyses, but then learn that the data is not able to support such analyses. This is what happened. I was excited to use survey data to measure the potential effectiveness of a fresh produce delivery program to food insecure patients, but the survey data did not have the correct questions asked or the correct controls to be able to support analysis of the program as an intervention. Instead, I have had to change my way of thinking and change the scope of the project due to limitations of the data, which is how it should be. You cannot make data do what you want it to do; you can only work within its limitations.

Scientific failures are failures in name only. In reality, they are lessons learned that continually improve the project. With perspective, what seems like limiting failures are actually opportunities to explore other avenues. So, I have designed the analysis as a cross-sectional study of the delivery program participant’s demographics. In addition, since there are survey measures for pre- and during COVID, I am able to measure food insecurity and stress scores as they are impacted by COVID, which has shed new light on how the program participants have been coping with the pandemic. What an opportunity, and I have happily shifted gears towards these analyses.

Next Steps

Overall, my contributions have helped to frame the data that this program has towards exploring its food recipients and making internal improvements. I have helped to describe what additional steps they need to take and what additional data needs to be gathered in order to explore the actual efficacy of the program. New surveys for participants are now being designed and will be employed soon. Ideally moving forward, this program will improve food security and stress levels in these patients, and can be used as a model framework for other communities. Further down the line, the hope is that programs such as this one will improve health conditions in the community, but this would require major shifts in food insecurity over a longer term in order to be able to measure changes. I look forward to the continued betterment of community health through nutritional access – a lofty goal, but a necessary and long-awaited one.

Explaining Food Insecurity

Food insecurity is a term officially set to describe when a household cannot acquire enough food to meet the nutritional needs of all of its members. Households can be singular or include multiple persons. It is considered to be a social determinant of health, since food insecurity is tied to income and can be an important predictor of unhealthy eating behaviors which lead to higher rates of diabetes and heart disease, for example. Closely related to lack of access to nutritious food, food insecurity is also associated with high costs of healthcare due to increases in acute and chronic health conditions. Overall, food insecurity is highly detrimental to both the individual and the community, and addressing population health requires addressing it.

Food Insecurity as a Medical Priority

Shifting priorities to disease prevention and not just snapshot care or even longitudinal symptom care is a continuous discussion in the medical field. Is it our duty to not only treat symptoms of current medical conditions, but to prevent further harm from coming to our patients whenever possible? This is a point of contention since it requires a more holistic view of patient health and how this arises from the patient environment and community conditions. It stretches the fabric of what it means to be a healthcare practitioner and what it means to invest in patient health.

One of the major methods for linking patients with other resources in their community to promote their health is through the use of community health partners (CHPs). CHPs are often individuals but can work for local organizations such as churches and support services, which are often trusted in low-income communities. They are much better equipped to bring resources to their communities than a larger tertiary medical center, for example, which may be viewed with distrust. It takes a village to raise a person, but this concept also pertains also pertains to maintaining their holistic well-being. It takes the work of many to transform community culture to one of proactive health. Clearly, there is space to form better partnerships between patient clinics and community health organizations in order to improve community health, especially in regards to improving food insecurity as a social determinant of health. These partnerships have been popping up all over the country, including here in Durham!

Duke Outpatient Clinic Meets Farmer Foodshare

Delivery of food to vulnerable patients decreases food insecurity. This is a no-brainer, and is a model that has previously been used in many communities, as nutritional supplementation improves disease complications and can reduce emergency visits and other costly health expenditures. Food delivery in the age of the COVID pandemic is also especially relevant. Food insecure patients from the Duke Outpatient Clinic (DOC) are referred to a Duke organization called Root Causes, which partners with Farmer Foodshare to package and distribute weekly bags of fresh produce to these patients. Patients receive fresh produce and other items as well as recipes and information about health-promoting behaviors. This relationship not only provides necessities but also builds rapport between patients and their healthcare team.

It is pertinent to allocate resources to this at-risk population. The patient population served by the DOC is disproportionately poor, black, elderly, and affected by chronic diseases including diabetes and heart disease – all significant risk factors for COVID-19 co-morbidity. They are also common conditions amongst food insecure persons due to lack of nutritional food access. Starting with this population and addressing their social determinants of health through clinic-community partnerships is a key step towards improving community health in Durham, a model that could be extended across the country.

My research with Farmer Foodshare aims to examine the biweekly delivery of fresh produce and shelf stable items to our low-income, food-insecure patients referred from the Duke Outpatient Clinic. This analysis hopes to find increasing food security and reduced perceived stress levels due to enrollment in the program. We are taking a snapshot look at food insecurity in this population and how we might better serve them as this program continues to mature. I look forward to reporting back soon with all that I have learned over the course of this project. Until then – stay happy, stay healthy, stay in community.

Project Recap

Let’s do a quick recap on the project I have been working on. Food insecure patients from the Duke Outpatient Clinic (DOC) are referred to a Duke organization called Root Causes, which partners with Farmer Foodshare to package and distribute weekly bags of fresh produce to these patients. It is pertinent to allocate resources to this at-risk population. The patient population served by the DOC is disproportionately poor, black, elderly, and affected by chronic diseases including diabetes and heart disease – all significant risk factors for COVID-19 co-morbidity. My research with the organization aims to examine the biweekly delivery of fresh produce and shelf stable items to low-income, food-insecure patients, in hopes of increasing food security and reducing perceived stress levels.

Project Detours

In this experience so far, I am learning a lot about how important it is to appropriately frame your research questions and draw out analysis designs before you start. New data has also shaped my perspective on this project. Sure, we all have pretty hypotheses designed and standing proud at the beginning of any research project. But hypotheses are often there to be proved wrong, at least in part. And they also serve to remind us that virtually everything is much more complicated and non-linear than we thought. This is certainly the case in determining FPP efficacy. Through some constructive feedback with a Duke community health physician, I realized that the analyses I have been conducting need a closer look at the a priori hypotheses of the study.  Essentially, there is a lot of data and a lot of analyses we have been itching to do, but we have lost sight of what the main dependent variable that we want to study is, and what independent variable we think is influencing this.

Let us explore this feedback. I have been utilizing the statement “the primary aim of this prospective observational study was to measure the impact of biweekly fresh produce delivery on the food security, perceived stress, and biological health markers of food insecure patients during the first five months of the Coronavirus pandemic.” If it is prospective, then what effect did we think that the produce delivery had on each of these scores?  It seems that the expectation or hypothesis was that a period of receiving food deliveries improved each of these measures. However, since we do not have a control group, it looks like you we are comparing those who reported FPP benefit against those who did not perceive benefit. This is concerning because that piece of data is currently only part of what we report in our current manuscript draft, at the end, whereas with the given hypothesis, it should be present throughout. Our physician notes that he is not sure that is what the study set out to measure, and we may need to regroup.

At this time, the way forward is to decide what the central hypothesis is in terms of outcome and independent/dependent variables.  We do not want to use any kind of patient parameters, regardless of how cool the data looks, that are relatively independent of the Food Delivery.  So how can we better capture something related to the food delivery itself?  This will require a more in-depth assessment of what data is actually available from the organization, and something I am working through now.

Let me be clear: we have some valuable data here.  We just need to approach it with a clearer question.    I am currently not just looking through data constructs from the organization, but also attempting some freehand conceptual models of variables and study design to more clearly delineate the data we have and what we can analyze and what we can even show with this data. I hope to share these models with my group shortly and get back on track with data analysis.

Project Status

There are many things currently in the works for this project, including some analysis restructuring, but fear not! What we DO know is that we have useful and interesting data that will be valuable to people trying to respond to the needs during this pandemic, which will be with us in one shape or form for many months to come, which makes what we’re doing here really important.

It helps that, through all of this, the people I am working with are thoughtful and inspired. They continuously push me to be involved in all aspects of the organization and really be immersed in the issue of food insecurity. Many, if not all, are involved in medicine, which provides the perspective of the “food as medicine” concept in many of our meetings and projects, and the desire to do better for our patients is pervasive. This is a highly motivating factor, as you can imagine.

Food insecurity was already an urgent need before COVID hit, but now with reduced access to many normal activities, our patients are struggling to maintain food access and mobility. In addition, continued delay of any further governmental aid is exacerbating the issue. If the collected data confirm the intervention to be successful in increasing healthy behaviors and reducing patient stress, especially during strenuous times such as during the COVID pandemic, it could be expanded to other communities to address food insecurity and improve health outcomes among a wider patient population. This means that the fresh produce delivery model to food insecure patients could have wide impact across other communities and other health networks.

Larisa Gearhart-Serna will be focusing on measuring the effectiveness of a fresh produce delivery program for food-insecure patients in the Triangle during COVID-19 with Farmer Foodshare.

During the COVID-19 crisis, food insecurities have been exacerbated, and community members are turning to nonprofits for emergency aid. Local farms are also struggling. Farmer Foodshare, the organization I am working with, sources fresh local produce from local farmers for distribution to those in need. Food insecure patients from the Duke Outpatient Clinic (DOC) are referred to the Farmer Foodshare program, which packages and distributes weekly bags of fresh produce to these patients.

The patient population served by the DOC is disproportionately poor, black, elderly, and affected by chronic diseases including diabetes and heart disease – all significant risk factors for COVID-19 co-morbidity. Their risk factors, combined with pre-existing mobility and transportation constraints, make it difficult and unsafe for these patients to go out to grocery stores for food. In turn, this hindered access to healthy food threatens the ability of the patients we serve to manage their diet-related chronic health conditions.

Since August 2017, Farmer Foodshare’s partnership with DOC has provided packages of fresh produce and food education materials to patients experiencing food insecurity in Durham. Before the COVID-19 outbreak, patients would visit the DOC for these resources. Since the COVID-19 outbreak, patients now receive fresh food and educational hand-outs delivered to their doorsteps biweekly. The hope is that supporting food security with fresh, local food can mitigate the effects of environmental health factors and their contributions to this population’s risk for COVID-19 infection.

I started working with Farmer Foodshare at the start of the COVID pandemic when they were in desperate need of more distribution day packaging and delivery driver volunteers. I am passionate about food insecurity issues having grown up in a low-income, minority, food insecure background. My biomedical education has also taught me a lot about the health issues connected to such food insecurity. Given my background as a biomedical scientist and PhD candidate, Farmer Foodshare brought me on board as a research co-coordinator in September, to analyze data from patients in the fresh produce distribution program pre- and during COVID. I was overjoyed to be integrated more fully into the organization and to put my skills to good use, toward moving their work forward.

I will backtrack and say that, as a PhD candidate with her own research, I had limited time to dedicate to Farmer Foodshare efforts like I wanted to have. Although I was onboarded as a research co-coordinator, much of the work I was able to do had to fit around my PhD research and other work. This fellowship allows me to have protected research time to dedicate to them, which is nothing short of a Godsend. Because of the time I can now devote, we are working on a manuscript and data figures that would never have otherwise been possible since it is very analytically intensive. Preliminary results are very promising and allude to the additional food insecurity and stress COVID has brought to our most vulnerable patients, but that the fresh produce program is helping. 88% recipients of the weekly produce deliveries agree or strongly agree that they have benefited from the program, which is gratifying.

This work is ultimately important because obesity, diabetes, and heart disease occur at a higher frequency in low-income communities for a variety of reasons, including lack of access to and inability to afford healthy foods. It is important that clinics address these upstream factors in order to keep their patients healthy. In Durham, food security is estimated to be 19.1 percent, higher than the average of 18.6 percent in the state of North Carolina. Food insecurity predisposes patients to eat calorie-dense foods high in fat, salt, and processed carbohydrates, which all contribute to poor health outcomes. Additionally, as discussed previously, the COVID-19 pandemic has exacerbated the inability for low-income communities to have access to nutritious foods.

It is pertinent to allocate resources to this at-risk population. My research with the organization aims to examine the biweekly delivery of fresh produce and shelf stable items to low-income, food-insecure patients, in hopes of increasing food security and reducing perceived stress levels. If the collected data confirm the intervention to be successful in increasing healthy behaviors and reducing patient stress, especially during strenuous times such as during the COVID pandemic, it could be expanded to other communities to address food insecurity and improve health outcomes among a wider patient population. Thus, the data analysis project that I proposed for this fellowship and culmination towards publication will be instrumental towards showing efficacy of the FPP, new grant development, and pursuing funding to continue to reduce food insecurity in Durham and beyond.

I hope that this project will further serve as a demonstration of the power of home delivery of fresh produce as a health-promoting activity. Providing effective services now, especially during the COVID pandemic, is an incredible step and will help Farmer Foodshare and peer organizations in advocating for and refining food-as-medicine interventions.  Together we will empower and equip the community to turn the tide of community health!