December 17, 2019

Exploring the CSA Model as a health intervention

A research project funded by the United States Department of Agriculture (USDA) and Blue Cross Blue Shield Foundation of Massachusetts.

This submission was written by Jessica O’Neill, Executive Director of Just Roots and co-author on the study’s resulting research findings, now published in the American Journal of Preventative Medicine and the American Journal of Public Health.

A small, western Massachusetts-based, nonprofit teamed up with a Boston-based doctor and a local Community Health Center to research the impacts of participation in a subsidized CSA farm share program. Their findings point to clear diet and health benefits, as well as broader societal and economic benefits.

Just Roots, located in Franklin County, the most rural and second poorest county in MA, is a food access and health equity centered nonprofit organization that founded and operates the Greenfield Community Farm. On this land leased from the city of Greenfield, Just Roots dedicates itself to growing healthy, local food for all people. Steeped in the belief that all people deserve access to the building blocks of health (the food we put in our bodies), and the understanding that socioeconomically vulnerable individuals often face poor access to nutritious food and bear a disproportionate burden of diet-related chronic illness, Just Roots leaned into reinventing the traditional CSA farm share model.

Traditional CSAs, a direct farm to consumer model premised on advance payment for a share of the harvest which the member collects during the growing and harvest season, are by-and large utilized by wealthy individuals. Just Roots sought to instead develop an “accessible farm share model,” available to all people regardless of economic circumstance. Based on constituent identified barriers (ex: affordability, transportation, cooking know-how), Just Roots launched its reinvented accessible farm share model seven years ago and became the leading SNAP (Supplemental Nutrition Assistance Program) enrolled CSA farm share program in Massachusetts in 2019.

Key features of the Accessible Farm Share model include: market style pick-ups where customers have choice of what they bring home (as opposed to a pre-boxed share), variety of share sizes, flexible pick-up locations including delivery to low-income housing developments and times that don’t restrict members to a certain day a week, transportation assistance, reduced fee shares (made possible through subsidy dollars that are derived from fundraising activities including sponsorships, events, and philanthropic support), flexible payment plans, diverse payment options including SNAP, customer care inclusive of text reminders, free tastings, cooking demonstrations, weekly news from the farm, recipes, cooking tips, and more.

Just Roots’ CSA members reported impressive health impacts. Members reported:

  • Eating scientifically significant portions of fruits and vegetables daily;
  • Improvement to weight;
  • Feeling more connected to community;
  • Improved mental and general well-being;
  • Increased awareness of local produce and how to use it;
  • Increasing cooking from scratch/meals made at home; and
  • Decreasing fast food/empty calorie consumption.

These anecdotal findings prompted Just Roots to pursue more formal research into its CSA model, in an effort to find stakeholders who benefit from the impacts of CSA participation who could be influenced to invest in the model thus making it more universally available, and to show that the model cold create an opportunity for healthier, more sustainable farms and healthier people concurrently.

In 2017, Just Roots launched (Im)Proving the CSA Model, a scientific research study funded by the USDA and Blue Cross Blue Shield Foundation of Massachusetts to explore the CSA model as a healthcare intervention.  Together with Dr. Seth Berkowitz of University of North Carolina, Chapel Hill (formerly of Massachusetts General Hospital) and the Community Health Center of Franklin County (CHCFC), Just Roots began the scientific research study with two key objectives:

1. Test whether a subsidized community supported agriculture (CSA) intervention could improve diet quality.

2. Estimate the population-level effectiveness and cost-effectiveness of a subsidized community supported agriculture (CSA) intervention.

Study methodology: From May 2017 – December 2018, we conducted a randomized clinical trial. Participants were primarily patients of the CHCFC and all with a body mass index (BMI) of 25 or higher. Health-related eligibility requirements beyond BMI were limited, aiming to study the impact of the CSA model on a broad demographic of health rather than on people experiencing specific health challenges. Individuals were randomized to one of two study groups: One to receive a subsidized CSA membership for two years, the other (the control) to receive healthy eating information produced by the USDA. Each group received $300/year for participation. The CSA intervention participants were required to purchase a CSA share from Just Roots.

The primary outcome indicators were the Healthy Eating Index (HEI) score (a USDA-developed measure of diet quality based on federal dietary guidelines), participant-reported metrics on health and well-being, food security and finance-related medication underuse, weight, blood pressure, and bloodwork. Cost savings were assessed through the development of a microsimulation model from nationally-representative demographic, biomedical, and dietary data and the data resulting from our study. We modeled two interventions: unconditional cash transfer ($300/year) and subsidized CSA ($300/year subsidy) looking at a ten year and lifetime timeline.

Results/Conclusions: The subsidized CSA farm share intervention resulted in a clinically significant improvement in diet quality (health), a decrease in food insecurity and proved societal cost savings.

Health Improvement: Specifically, when looking at “in-season” results (when the intervention was taking place) the CSA led to significant improvement in total HEI score compared to the control group. Starting from a mean overall HEI score of 54.93, the CSA intervention group resulted in an HEI score of 60.2, whereas the control group moved to 55.9, for a difference of 4.3 between the two groups, meaning that the CSA group reported eating healthier foods. Sensitivity analysis was conducted including out-of-season assessment, income, and education, and all found similar benefit for the CSA intervention group. Had all study participants completed the trial as expected, the HEI differential is estimated to have been an even greater difference of 4.8 between the CSA group and the control group. Regarding food insecurity, the CSA intervention group once again realized a greater degree of improvement compared to the cash/control group: the CSA saw a 20% reduction of food insecurity, from 31% - 11%. Meanwhile the cash intervention group saw a reduction of 10%, from 42% - 32%.

Cost Effectiveness: The study of the economic benefits of the CSA found that an annual investment of $600 in the CSA resulted in about $1,000 in cost savings each year to society. These savings take the form of local economic development through farm sustainability, and improved quality of life and ability to remain an active member of the workforce and community due to reduction in disabilities of participants thanks to healthier eating on the part of the CSA participants.

While our findings estimated that the CSA intervention was a good value (meaning that the intervention costs incurred to create improvement to health were reasonable), healthcare costs were not saved due to the cost of the CSA intervention. To achieve savings in healthcare, either the CSA would have needed to cost less to administer or the resulting health improvements would have needed to be greater. Just Roots thinks it is important to note that cost analysis was completed based on the study premise’s impact on a single individual.  Just Roots’ own data on our CSA shows that the CSA feeds an average of 2.5 individuals per membership, which would indicate that when that multiplier is applied, cost savings would likely change and may in fact result in much greater cost savings across the board. Further research would need to be completed to test this hypothesis.

More research is needed to test the model in other geographic areas, with more diverse populations to see if/how the results change and to better understand the cost savings impact when taking into consideration the multiplier effect of the CSA impacting more than one individual. Additionally, a study held over a longer period would allow for more robust healthcare cost savings conclusions. Finally, dissemination of the findings will work to engage a variety of stakeholders across sectors (private and public) and policy makers to invest in the CSA as a health intervention that now proves itself to be a benefit for local farms, local communities and local people. Just Roots is currently seeking funding to develop a training module based on its experience in reinventing the CSA as an accessible model. The module will be leveraged to scale the model regionally.  

If you’d like to learn more please contact Jessica O’Neill, Executive Director of Just Roots., 413-325-8969

⟨ Newer:
Climate Change Legislation would Impact Agriculture, Without Adequate Input from Farmers

Older ⟩
Materials from the 2019 MA Food System Forum