Mitigating Food Insecurity During the COVID-19 Pandemic: A Replicable Food Delivery Service Using Public-Private Partnerships

Summary

Stay Home, Stay Healthy (SHSH), a replicable food-delivery service, increased access to healthful food for vulnerable populations during the COVID-19 pandemic. It used community partnerships to identify families facing food insecurity and public-private partnerships to source and deliver food. We report on SHSH, its impact to-date, and lessons learned.

The COVID-19 pandemic disproportionately affected the elderly, people with low incomes, and Black, Indigenous, and People of Color (BIPOC) with high rates of disease and economic hardship.¹ Disruption to safety-net services acutely exacerbated food insecurity (FI).² Schools, senior centers, and food pantries, which act as foundational food-access points, closed or limited their services. Unemployment reached historic levels, particularly for hourly-wage workers, further lowering incomes and limiting access to food.³ Simultaneously, farms nationwide had an overabundance of produce amid plummeting demand from closed restaurants, businesses, and schools.⁴

In November 2019, our cross-disciplinary team of students, professionals, and faculty at The University of Texas at Austin (UT Austin) founded Good Apple (GA), a revenue-generating, physician-prescribed grocery-delivery service aiming to end FI in Central Texas.⁵ Good Apple uses a two-sided business model: A subscription-based produce-delivery service generates revenue from paying customers; that revenue in turn funds free grocery-delivery services to families facing FI.

When COVID-19 struck, traditional anti-hunger models struggled to adapt safely, scale up operations, and equitably distribute resources amid increasing FI and a rapidly changing food system.⁶ Our team saw an opportunity to fill this gap by using GA's infrastructure alongside philanthropy, public-private partnerships, and newly available human capital. In March 2020, GA launched Stay Home, Stay Healthy (SHSH), a program to serve older adults and people with chronic disease facing FI and high morbidity and mortality risks from COVID-19. Stay Home, Stay Healthy delivered food directly to people's homes, addressing FI and reducing infection risk through social distancing. This program was distinct from GA's revenue-generating services, and profits from GA's subscription service were used to fund parts of SHSH.

Program Model

Stay Home, Stay Healthy increased food access for families by delivering fresh fruits and vegetables and pantry staples such as grains, protein, and dairy to participants' homes. Each household received a one-week supply of food per person. Figure 1 illustrates central partners and processes.

Fresh produce was purchased at cost from local farmers, and a regional food bank provided pantry staples. A $20,000 grant from the City of Austin's Transportation Department and private contributions funded the first 2,000 deliveries, which were completed in 12 days. An additional $363,500 of philanthropic support facilitated the purchase of more food and supplies to scale up the volume of deliveries.

A volunteer force of community members prepared and packed groceries in accordance with Centers for Disease Control and Occupational Safety and Health Administration workplace guidelines, including limiting size of in-person gatherings,

Figure 1.

Good Apple's Stay Home, Stay Healthy (SHSH) program used partnerships to provide free grocery-delivery services to older adults and people with chronic illness during the COVID-19 pandemic.

and maintaining social distancing, face coverings, hand hygiene, and frequent disinfection of high-touch surfaces.⁷ Philanthropic funding was used to hire five packers at $11/hour, six drivers at $15/hour, and six management staff at $15–28/hour, thereby directly providing wages to people who had lost employment during the pandemic. The city's bus system, whose ridership had declined precipitously, provided vehicles and dispatch operations for direct-to-door delivery. With this critical in-kind support, the unit cost of groceries delivered per person was $14. Use of GA's existing business infrastructure allowed cost-sharing for facility and operational expenses. Without volunteer or in-kind support, we estimate a cost of $18 per person based on a model that includes facility costs and dispatch operations and doubles the paid packing and driving workforce described above.

To identify families in greatest need, SHSH built on GA's original model of clinic-based referrals while incorporating substantial outreach to broader community groups, local housing authorities, and hospital systems. Community groups included religious organizations, local justice coalitions, Latinx health promotion teams, and LGBTQ+ advocacy organizations. Stay Home, Stay Healthy disseminated enrollment information with the goal of equitably serving Austin's highest-risk individuals. In addition, the program promoted services via citywide COVID-19 resource-sharing networks and local media coverage.

Both self-enrollment and referral options were available using an open-access, online survey offered in English, Spanish, Mandarin, Vietnamese, and Arabic. A multilingual phone hotline provided an enrollment option for clients without internet access.

Implementation and Impact

Since March 2020, SHSH has delivered over 800,000 pounds of groceries to over 26,000 individuals in over 3,570 unique households across Austin. Over 1,300 households received repeat services. In Austin, 34% of residents identify as Latinx and 7% of residents as Black.⁸ However, Latinx patients represent 58% and Black patients 10% of people hospitalized with complications of COVID-19 in the city.⁹ Of SHSH recipients providing race-ethnicity data at enrollment, 55% identified as Latinx and 21% as Black, indicating the program reached groups at high risk for adverse outcomes.

We solicited feedback from clients and community partners. Upon grocery delivery, 87% of surveyed recipients stated they received the right amount of food, 38% stated they would not need to visit a grocery store that week, and 27% said they might need to go to a store for small items. These responses suggest SHSH helped many families avoid high-risk exposure areas such as grocery stores, food pantries, and public transportation.

Lessons Learned

Addressing FI during a pandemic is a dynamic challenge. COVID-19 quickly exacerbated existing disparities in food access. Stay Home, Stay Healthy was created to prioritize equity in resource distribution at a time of unprecedented uncertainty and economic hardship. We reflect on the diverse public-private partnerships across academia, industry, community organizations, and government and on how each relationship was essential to the success of SHSH; we articulate five lessons for programs that want to adapt our processes to address FI in their own communities.

Expand the reach of local farms and food pantries

Stay Home, Stay Healthy worked with local farmers to redistribute unsold fresh produce and local food pantries to supplement deliveries with proteins, grains, and dairy. Existing relationships with local farmers helped quickly identify surpluses of fresh produce available due to lower demand during the pandemic. Local food pantries saw higher demand for their services given acutely rising FI and financial strain, but they lacked the organizational infrastructure to pivot towards delivery services. Working with SHSH, which had fewer operational constraints, helped to reconnect farms and pantries to their clients. In effect, SHSH connected valuable community resources to a pipeline of recipients whom neither farmers nor food pantries could have readily accessed with their existing outreach structures.

Amplify messaging through medical clinics, community organizations, and local media

A central aspect of building an equitable distribution network involved developing partnerships with GA's existing referring medical clinics, as well as relying on relationships with trusted community organizations and local media to share sign-up information. Collaboration with the local housing authority allowed for marketing to clients at their homes, which was essential because of shelter-in-place policies. Stay Home, Stay Healthy created inclusive enrollment through online and phone sign-up while offering information in five languages based on community feedback. Media advertising allowed for citywide reach via local news and radio segments, permitting residents to direct resources to neighbors in need or family members while maintaining social distancing.

Build relationships with local government; draw on existing knowledge

In January 2020, GA was awarded seed funding under a novel collaboration between the Austin Department of Transportation and Ford Motor Company, with the aim of addressing transportation barriers to food access. In March 2020, already aware of GA's existing infrastructure, the city quickly invested in SHSH by funding the first 2,000 deliveries. City government support validated SHSH as a reliable resource for city residents. Showing proof of concept and later demonstrating scalability allowed for quick pursuit of additional funding in a time of high philanthropic interest from both individuals and corporations. Stay Home, Stay Healthy benefited from working with local government, which had important neighborhood-specific data, as well as access to human and financial capital, such as multilingual interpreters and funding resources.

Redirect the talent and skills of transportation workers

At the start of the pandemic, public transit ridership dropped precipitously. Austin's metro system offers door-to-door services for adults with disabilities, but the fleet sat idle as stores, restaurants, and clinics closed in-person services. Stay Home, Stay Healthy worked with this uniquely qualified cohort of drivers, who had nuanced knowledge of and rapport with the community, to transition to food delivery. The metro system's administrative teams offered logistical support for route-planning and delivery-timing. For deliveries outside the metro service area, SHSH hired drivers through private transit companies who could no longer rely on wages from rideshare employment. In effect, public transportation, which was hit hard at the onset of the pandemic, proved to be an asset when encouraged to pivot its services to an emerging need. Outside of pandemic contexts, rideshare drivers can be used to provide food delivery services to communities in need. Additionally, partnership with metro programs serving adults with disabilities could be explored to offer additional resources such as food or medication delivery at the time of transportation service.

Extend the practical reach of academic expertise

Good Apple originated within the academic medicine community with a group of medical students and faculty focused on how social entrepreneurship and health intersect. Stay Home, Stay Healthy continued to draw on expertise from the university. The model provided valuable opportunities for service learning, such as assisting with multilingual client intake, packing fresh groceries, and studying SHSH's impact. The volunteer network spanned graduate and undergraduate programs at a public university, a local community college, and three local high schools. In addition, the university's connection to philanthropic networks facilitated ongoing financial support during a period of high need and rapid operational growth. In addition, SHSH can rely on academic expertise to rigorously study the program's impact and to draw lessons for future programs, as this article aims to do.

Future Analyses and Applications

Throughout the program, quantitative and qualitative feedback was collected to tailor food deliveries to clients' nutritional needs and preferences. Demographic data were collected to gauge which neighborhoods and communities were connecting with SHSH's outreach efforts. In addition, survey data informed how clients were using their food deliveries and altering exposure to high-risk environments during the height of the pandemic. Lastly, data collected on anxiety (using the validated Generalized Anxiety Disorder-2),¹⁰ depression (using the validated Patient Health Questionnaire-2),¹¹ rates of chronic disease, food insecurity, and transportation access will be used to study how SHSH influenced clients' health and financial outcomes.

While those analyses will inform GA's ongoing work and the city's continuing efforts to address food insecurity, evidence from individual clients' experiences underpin the lessons already learned from the project. Consider this example:

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Mary, one of GA's first clients, was referred by her local food pantry in November 2019, just before the pandemic. At age 62 and the caretaker for her four grandchildren, Mary suffered from advanced heart failure. To provide food for her family on her fixed income, she rode the bus twice per month to multiple pantries, but healthful options were limited and inconsistently available. In March 2020, the pandemic exacerbated Mary's limited access to adequate, nutritious food: Her four grandchildren were home full-time without school breakfasts and lunches; bus rides suddenly presented an exposure risk given her underlying health condition; and she could not access drive-through services at food pantries without a vehicle. She struggled to feed her family of five on just $172 per month in Supplemental Nutrition Assistance Program benefits.

Making use of GA's existing infrastructure, SHSH mobilized resources to help Mary and thousands of others in similar circumstances. Stay Home, Stay Healthy delivered fresh produce from farming partners instead of letting that food go to waste amid restaurant closures and lower demand. Mary's local food pantry extended its reach by delivering grocery staples directly to her. Bus drivers who had previously driven Mary to the pantry now delivered her food, helping her avoid potential exposure to COVID-19 on public transit and in other often-crowded settings.

Using cross-sector public-private partnerships, SHSH created longstanding relationships with a diverse client base and addressed FI. The lessons enumerated can be applied even outside pandemic crisis situations, and some may represent new potential best practices for mitigating food insecurity. Further studies on how food delivery affects health and financial outcomes will be valuable to GA, the City of Austin, and others working to address food insecurity in the post-pandemic recovery phase and beyond.