Improving Nutrition Security for Individuals With Serious Mental Illnesses: A Partnership of Public and Nonprofit Agencies

Two state agencies—the New York State Office of Mental Health (the site of the two psychiatrists serving as coprincipal investigators and project staff) and the New York State Department of Agriculture and Markets—partnered for this pilot project. The latter agency promotes New York agriculture and its high-quality and diverse products; fosters agricultural environmental stewardship; and safeguards the state’s food supply, land, and livestock. The agriculture department also aims to improve consumers’ access to fresh, local foods statewide through farmers markets and farm-to-school programs. Together, the two state agencies approached two well-established mobile farmers market operators (Capital Roots and FeedMore WNY [Western New York] in Albany and Buffalo, respectively). Concurrently, the project team partnered with two well-established mental health housing providers (Rehabilitation Support Services in the Albany area and Buffalo Federation of Neighborhood Centers), which operate licensed community residences (group homes that provide three meals a day, with input from residents) as well as supportive housing apartments. Those living in apartments have more independence than do those living in community residences; apartment residents are responsible for managing their own grocery shopping and food preparation, although they still interact with staff who provide rehabilitative services designed to improve residents’ functioning and promote independence.

Both housing agencies serve populations with a high prevalence of not only food insecurity but also other adverse social determinants of health (e.g., low income, unemployment, disconnection from family, discrimination) driven by the presence of a serious mental illness and often by race-based inequities (e.g., approximately 25% and 60% of residents at the Albany and Buffalo sites, respectively, are African American). From the beginning, the project team recognized that people of color, who are broadly subject to health inequities, are overrepresented in the population living with serious mental illnesses in the targeted housing settings. The racial and socioeconomic demographics of this population reflect underlying systemic inequities, which the project was intended to combat.

The intervention’s three components are structured around three pillars of food security: food availability pertains to supply and distribution, or sufficient quantities of food being available consistently; food access relates to affordability and allocation, or having sufficient resources to obtain appropriate and nutritious food; and food use is about knowledge of basic nutrition and meal preparation, including food safety and proper preparation and cooking methods. Partnerships were necessary for implementing each component because the intervention is outside the scope of typical mental health services. Indeed, multiple partners were involved in the implementation of the intervention’s third component: creating a curriculum that enhances both knowledge and self-efficacy regarding preparing and eating fresh produce.

The intervention is structured around three pillars of food security, although our interest pertains more precisely to nutrition security. First, to ensure a consistent source of nutritious food (food availability), we are bringing farmers markets to where people live by partnering with existing mobile market providers. Whether they live in food deserts (3) or are restricted in their activities (e.g., transportation limitations), many individuals with serious mental illnesses face chronically restricted food options (e.g., when and where to shop, what to purchase). In both Albany and Buffalo, we are partnering with existing mobile markets to schedule a weekly stop at the housing agencies. These mobile markets are retrofitted delivery vans or box trucks that travel to designated locations to increase community members’ access to fresh produce. They afford community members—now to include our target population of housing agency residents with serious mental illnesses—the opportunity to select and purchase fruits and vegetables. Additionally, the mobile market stop is not restricted to our target population but also serves any local community members. Therefore, the mobile market stop also enhances community inclusion and integration of our target population.

Second, to help ensure that residents have sufficient resources to purchase food (food access), our state partner (the New York State Department of Agriculture and Markets) is providing our target population with access to an existing program that incentivizes the purchase of produce at both traditional farmers markets and mobile markets. Specifically, they supplied 3,750 FreshConnect Checks to both housing agencies. These checks were distributed to residents regardless of whether they qualified for SNAP or related benefits. The hope is that the FreshConnect Checks will serve as incentives for residents to use SNAP benefits at the mobile market, because the FreshConnect Checks program provides a voucher worth $2 for every $5 in SNAP benefits spent at farmers markets. Because of the complex psychosocial disadvantages and symptoms associated with serious mental illnesses and their treatments, affected individuals experience unique barriers to using programs that connect food-insecure communities with farm-fresh produce. In other states, similar voucher programs also connect underserved individuals to affordable and healthy food by incentivizing the use of SNAP benefits at farmers markets (6).

Third, to convey information about nutrition and food preparation (food use), we assembled a work group of content experts and key stakeholders to develop a group-based curriculum on this topic, and then we partnered with the housing agencies to train selected staff on the curriculum for their residents. Because many individuals with serious mental illnesses may not have had opportunities to develop the skills and independence that facilitate nutritious diets incorporating the federally recommended amounts of vegetables and fruits, the curriculum was designed to focus on the preparation of produce available in the mobile market. Although multiple existing curricula were reviewed, none seemed ideal for our target subject (fresh produce) and target population (those with serious mental illnesses served by behavioral health housing providers). Curriculum development work group participants included a chef who is engaged in community food-related activities, a resident of one of the housing agencies who has lived in community residences, a peer specialist, several dieticians and nutritionists with expertise in nutrition education, and psychiatric rehabilitation staff.

Using the “tell, show, do, and review” instructional technique, the curriculum educates residents through hands-on activities on a range of competencies, including planning healthy meals, shopping for fresh produce at the mobile market, choosing healthy snacks, following recipes, and using different techniques to prepare food. Among other topics, the curriculum—which both conveys information and offers group-based opportunities to practice skills in the kitchen—covers sautéing, steaming, and roasting vegetables.

The process reflects a psychiatric rehabilitation model targeting skills development to enable more independent living. We aimed to include cultural considerations in curriculum sessions; for example, discussion prompts include “How has your current diet been influenced by your upbringing, culture, and experiences?” and “Within your culture or community, are there certain vegetables that people like to roast?” Two work group members heavily involved in curriculum development trained residential staff at the respective housing agencies to deliver the six-lesson curriculum. Partnerships were once again integral, in that the curriculum instructors are residential staff at the housing agencies, and staff play a major role in the buy-in of residents (e.g., residents’ decisions to participate in the curriculum). One potential challenge was the varying levels of staff members’ familiarity with nutrition issues, so self-selection to be an instructor and the provision of engaging training and ongoing support were important.

Engaging both the New York State Department of Agriculture and Markets and the mobile farmers markets entailed some initial discussion about the problems to be addressed, including the facts that those with serious mental illnesses are disproportionately burdened with adverse social determinants of health (including food and nutrition insecurity), are less likely to use existing incentive programs related to purchasing fresh produce, and represent a special population warranting targeted intervention. Engaging the housing agencies entailed describing all three components of the intervention and planning how each would be incorporated into existing programs and processes. Sustained engagement across partners was accomplished by providing regular feedback on progress and ensuring that the project advanced each agency’s mission (e.g., the agriculture department was reaching a new population with its FreshConnect program, the mobile market provider was reaching a new population while having another stop with a sufficient customer base, and the housing agencies were providing a new service to better the health of their residents).

The partnerships created to implement the intervention allow us to leverage, on the one hand, existing public funding for healthy food purchases and, on the other hand, nonprofit agencies for improved produce access and training of residents. If the initial implementations are successful, these partnerships will allow for scalability and sustainability.

Like design and implementation, evaluation of our project also requires leveraging our partnerships. To this end, research staff at Columbia University and the New York State Psychiatric Institute have come together to plan and conduct a mixed-methods evaluation of the pilot project. In a step that is critical to preparing for large-scale implementation, sustainability, and research, the study team is collecting three types of evaluation data. First, to evaluate feasibility, the study team is gathering data on key process measures, including the number of residential staff trained to deliver the curriculum, the number of residents receiving the group-based curriculum, the types of produce purchased, the amount of money spent, and other metrics. Such process measures are needed for planning a larger project. Second, to evaluate acceptability, the study team is conducting 26 audio-recorded interviews with residents receiving the intervention, residential staff delivering the curriculum, leadership at the housing providers, and mobile market staff. Interviews are structured around interview guides, and the transcribed interviews will be analyzed with qualitative methods. We included cultural considerations in the acceptability interviews. For example, the interview guide for residents includes questions such as “What foods from your culture weren’t in the class?” and “What foods from your childhood would you like to have added to the class?” Third, precurriculum and postcurriculum quantitative data are being collected on knowledge about fresh produce and its preparation, self-efficacy for preparing and eating fresh produce, and meal independence. Effect sizes will be estimated to power a larger study. If the data indicate the intervention is feasible and acceptable, future research could examine its impact on physical and mental health–related outcomes.

We plan to expand the pilot project to an additional housing provider, ultimately aiming for replicability in behavioral health housing sites statewide. We will also conduct key stakeholder interviews to understand what implementation and dissemination would look like in other residential contexts—specifically, for youths in residential treatment programs, people with intellectual or developmental disabilities living in group homes, and people in substance use disorder treatment in residential treatment programs. If replication occurs in other communities and further program expansion is considered, cultural considerations should be at the forefront in developing and implementing the program. This will be best accomplished by involving diverse stakeholders (especially the end users of the intervention) from the local community. As expansion is considered, we will pursue other evaluation goals, such as determining the ways in which the intervention components might influence the types of purchases made with FreshConnect Checks, SNAP, or other benefits.

Additional partnerships may be needed both to improve food and nutrition security and to ensure sustainability. For example, in future work, we may consider partnering with faith-based organizations, which operate a large share of food pantries. Given that many individuals in our target population may use food pantries at some point—such as when moving from group-based living arrangements (where meals are provided) to more independent housing—this additional partnership might increase the impact of the intervention. Finally, identifying other potential partnerships will be important to planning for further expansion. For example, given that most program participants receive Medicaid, we will consider including health providers as partners who may be able to provide produce prescriptions that could be covered by Medicaid as part of the move toward value-based payment and requirements around partnering with community-based organizations to address social determinants of health.

This project, enabled by multiple partnerships, presents an opportunity to empower individuals with serious mental illnesses living in community residences and in supportive housing apartments, as well as residential staff, to learn about and develop healthy eating habits. Beyond educating participants on nutrition and cooking basics, both logistically making healthy food more accessible and reinforcing the enjoyment gained by preparing and eating healthy food will improve sustainability of the intervention. We hope that improving access to, affordability of, and knowledge and self-efficacy around fresh produce will lead to sustained behavioral change that will ultimately improve overall health as well as the mental health status of program participants.