Food insecurity, that is, the lack of consistent access to nutritious and affordable food, is associated with poor diet, increased cardiovascular disease (CVD) risk, and has a negative long-term impact on the economy through increased health care costs. CVDs and food insecurity disproportionately affect Black and Hispanic families, and most of these racial health disparities can be attributed to social determinants of health, including poor access to healthy foods. A recent policy in the U.S. authorized the Supplemental Nutrition Assistance Program (SNAP) benefits to be used online to increase grocery access and promote healthy eating. Although online grocery shopping has been growing among populations of low-income, the selection of fruits, vegetables, and legumes (FVL), which are protective against CVD, is lower than in-store. Distrust of online hired shoppers' choices, fear of losing money on unsatisfactory purchases, and impulse of unhealthy food purchases have been the major barriers to online healthy food selection. Thus, there is a need for intervention packages that are effective, economical, and easily scalable into policies that address CVD-related outcomes and improve health equity. The proposed work will use a highly efficient methodological approach, the Multiphase Optimization Strategy (MOST), to test three experimental components aimed at barriers to online healthy food selection, called OPT-FRESH. This approach addresses weaknesses in prior studies, which cannot determine which elements of multicomponent interventions meaningfully improve outcomes. 360 families with children living in low-income urban communities of NYC will be randomized to receive some combination of the three experimental components for 12 weeks: 1) weekly text messages to improve the trust in online grocery services (off/on); 2) weekly match-up to $10 as a financial incentive for purchasing FVL online targeting loss aversion (off/on); 3) weekly instant shoppable grocery lists of culturally tailored meal suggestions using SNAP recipes targeted at impulse purchases (off/on). Delivery fee waiver and a tutorial video addressing digital literacy will be constant components to promote equity in participant enrollment. Aim 1 will determine the combination(s) of the three experimental components that improve overall household FVL purchase and food insecurity (primary outcomes) and FVL intake of children (secondary outcome). Aim 2 will identify the optimized intervention that balances component(s) that are affordable and scalable (high adoption, implementation, maintenance) that still produce meaningful effects on the outcomes, using decision analysis for intervention value efficiency. Aim 3 will determine the mechanistic effects of the three intervention components on the outcomes using factorial mediation analysis. Working with community-based organizations and nutrition and hunger relief programs in NYC, a grocery delivery service, and a team with unparalleled expertise in experimental trials, policy, and MOST, we will implement optimized, affordable, and scalable intervention strategies to improve neighborhood food access and ultimately CVD outcomes in socially vulnerable families.

OPT-FRESH will use a highly efficient methodological approach for intervention development, the multiphase optimization strategy (MOST). We will partner with the private sector (Instacart) to leverage strategies from the public sector (SNAP) and test three experimental components aimed at barriers to online healthy food selection. The three experimental components, which were found in our pilot work to be feasible and acceptable, include: 1) weekly text messages to improve trust in online grocery services; 2) weekly match of up to $10 as a financial incentive for purchasing FVL online; and 3) weekly instant shoppable grocery lists of tailored meal suggestions using SNAP-Ed recipes. Moreover, as our pilot demonstrated that waiving delivery fees enabled more equitable participant enrollment and online grocery uptake, all participants will have the online delivery fee waived for the intervention period (12 weeks), along with a tutorial video addressing digital literacy to further promote equity in enrollment. A sample of 360 families with young children living in low-income urban communities of NYC will be randomized to receive some combination of the experimental components for 12 weeks. We will test component effects at 12 weeks and test maintenance in the absence of intervention (no fee waiving, experimental components) 9 months post-intervention.

We will conduct additional formative research before the intervention is implemented to ensure Cultural tailoring of OPT-FRESH. We will hold 2-5 focus group discussions with caregivers of young children with low-income to gather feedback on intervention materials and research procedures informed by key areas of the Ecological Validity Model: i) Language-feedback on intervention materials, including a tutorial on using Instacart; ii) Persons-recruitment and "buy-in" factors; iii) Metaphors-symbols and sayings that resonate with participants; iv) Content-grocery items needed to address food insecurity, including culturally appropriate options; v) Methods-feedback on text messages, online surveys, and intervention delivery; and vi) Context-barriers to participation and adherence. Then, a group of approximately 10 SNAP-eligible adult caregivers of children will be invited to form our community stakeholder team. They will be engaged throughout the intervention to include their voices and lived experiences in the project. The group will meet virtually once or twice a year to provide feedback on key areas of the intervention.

Inclusion Criteria:

• Adult (> 21 years old)
• Live in a household with a young child(ren) under the age of 10 years and above age 2.
• Primary shopper for the household
• Have access to a smartphone or computer to place online orders
• Participation in the Supplemental Nutrition Assistance Program in the past year or income eligible (annual household income =< 130% of the federal poverty line)
• Agree to share itemized grocery receipts during the study (12 months)
• Willing to order groceries online
• English or Spanish speaker
• Informed consent

At this time, there are no plans to share IPD due to limitations related to participant privacy, the sensitive nature of the data collected, and constraints in the informed consent process that do not allow for broad data sharing. While we support data transparency, any future sharing would require additional ethical review and participant re-consent to ensure privacy protections are upheld.