Title: Fresh Street: a cluster randomised controlled trial of the benefits of a place and household-level subsidy for fresh fruit and vegetables on diet, health and the wider environment
Funder: Department of Health and Social Care

Abstract: FRESH Street_x000D_ Many communities in the UK are unable to afford, or access, all the food needed to make up a healthy diet. Despite national healthy eating information campaigns (e.g. 5-A-Day), and support for families on low incomes (Healthy Start), only one in five people eat the recommended 5 daily portions of fresh fruit and vegetables. _x000D_ We want to test a new approach (Fresh Street) to help improve diet and health. The Fresh Street scheme provides vouchers for fresh fruit and vegetables to households. Vouchers worth £5 are delivered to households every week, along with a vegetable-based recipes, brief nutritional information and healthy eating advice. Unique features of the scheme are that: (i) vouchers are offered to households (not individuals), (ii) all households are eligible (regardless of size or income), (iii) vouchers can only be used with local independent fresh fruit and vegetable sellers (not supermarkets), and (iv) households are encouraged to share vouchers, if they wish._x000D_ This approach was developed with residents in Barnsley, an area of high deprivation in the north of England. The scheme was then tested in four streets (95 households) for a year to see if it was deliverable and acceptable. The scheme was popular with most (84%) of all eligible households joining the scheme. Most householders reported that the scheme helped them buy and eat more fruit and vegetables and most (89%) of all of the vouchers being used. Many described how it prompted them to think about eating healthily. People frequently talked about their health, and some reported that they had lost weight since joining the scheme. Local fruit and veg shops and stalls reported new customers and that existing customers were buying more. There were also signs of increased social connection (shopping together, eating together, and sharing vouchers and food). _x000D_ Local authorities and researchers now want to test the effectiveness of this ‘place-based’ voucher approach on improving local food choices, diet, health and the wider environment. _x000D_ We will study this approach in two areas of deprivation where diets are low in fresh fruit and veg (Doncaster and Withernsea). In the first year of the study we will work closely with local residents, fruit and veg vendors, councillors, authorities and organisations to ensure that the scheme fits well with local priorities and resources (e.g. cook and grow schemes). Before we start the scheme we will test the methods we want to use to assess the scheme - short questionnaires and conversations (both online and door-step) in order to make sure that the methods we use are acceptable to householders. Throughout the study we will carefully listen to householder’s stories and experiences of the scheme and ask them to help us make sense of these experiences. We will also talk to local fruit and veg vendors and other local key people involved in health and food. We will also obtain anonymised level health data on GP and hospital visits for each area to see if the scheme has an effect on NHS healthcare use. We will test the scheme for two years in 34 streets (selected at random) and compare what happens in 34 similar streets without the scheme. _x000D_ This study will help us understand the effect of the scheme on the diet and health of households (including families with children) and communities (streets). Throughout the study and after, we will share knowledge gained with local people and the wider research community.

Lay abstract: Research question _x000D_ What are the effects of a multi-component place-based voucher approach on local food choices, diet, health and the wider environment? _x000D_ Background_x000D_ Many communities in the UK are unable to afford, or access, the food needed to make up a healthy diet. Despite national healthy eating information campaigns (e.g. 5-A-Day), and support for families on low incomes (Healthy Start), only 20% of the UK population eat the recommended 5 daily portions of fruit and vegetables (FV). _x000D_ Methods_x000D_ We will test a multi-component approach to increase the capability, opportunity and motivation of households to purchase and eat fresh FV (Fresh Street). This innovative approach combines local fiscal measures (5 x £1 weekly vouchers), seasonal veg based recipes, brief nutritional information and healthy eating messages. Key features are: (i) vouchers are offered to households (not individuals), (ii) all households are eligible, regardless of size, type or income, (iii) vouchers are only redeemable with local independent retailers of fresh FV (not supermarkets) and (iv) households are encouraged to share vouchers. This combination allows connections to be leveraged for mutual benefit within local systems relating to diet, health behaviours, health, and the broader social, economic and physical environment._x000D_ Fresh Street was recently developed and tested over 12 months in 4 streets (95 households) in an urban part of Barnsley, an area of high deprivation in the north of England. Most (84%) eligible households joined the scheme, and 89% of the vouchers were redeemed. Information on the impact of the scheme was collected from retailers and conversations with households who joined the scheme. Many reported that the scheme helped them buy and eat more FV and prompted them to think about eating healthily. People frequently discussed their health and health behaviours._x000D_ Aims and objectives _x000D_ The aim is to provide evidence for decision makers on the impact of a place based household-level subsidy for fruit and vegetables (‘Fresh Street’) on diet, health and the wider environment in areas with low FV consumption and high deprivation. We will explore the impact of the intervention on individuals, households, and communities. _x000D_ Methods _x000D_ In year one we will work with residents, councillors, authorities and organisations to ensure that the intervention fits with local and national priorities and assets, and refine the trial protocol. In years 2 & 3 we will test the scheme using a pragmatic cluster randomised controlled trial with a parallel process evaluation and economic analyses. Impact will be assessed via household surveys, doorstep interviews with local people, and anonymised cluster level data on primary and secondary healthcare use. This complex intervention has the potential to impact on multiple domains within local food systems, we have adopted pluralistic (and interdisciplinary) approach to the choice of outcomes. The primary outcome is dietary quality (measured using a short food frequency questionnaire). Secondary outcomes include: FV consumption, red meat consumption, life satisfaction, food insecurity, health, health related behaviours, health service use. _x000D_ Anticipated impact and dissemination _x000D_ This study will provide evidence for a wide range of local and national decision makers and service providers on how the intervention can improve food security, dietary wellbeing, health and social outcomes within low-income communities

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE