Improving Rural Health Through Nutrition Incentives: a Mixed Methods Evaluation of the First Year of the Appalachian Farmacy Program

Food insecurity remains a critical public health concern, particularly in rural, low-income communities. In 2023, 13.5% of United States households experienced food insecurity, with rates in Tennessee (15.6%) exceeding the national average. Produce prescription programs have emerged as a strategy to improve food access and promote healthier eating behaviors. This study presents an evaluation of Appalachian Farmacy, a produce prescription program in Northeast Tennessee designed to increase fruit and vegetable consumption among individuals receiving Medicaid, Medicare, or Supplemental Nutrition Assistance Program (SNAP) benefits. Program evaluation methods included semi-structured interviews for process evaluation and preand post-surveys for outcome evaluation. Interviews explored participant experiences, perceptions of the program, and barriers to participation, with transcripts analyzed using rapid coding in Microsoft Excel 2019. Surveys were administered at enrollment and after 1 year, with questions adapted from the Nutrition Incentive Hub. Qualitative process evaluation themes included mixed accessibility and ease of voucher use, encouraged changes in eating behaviors, increased produce intake, barriers to participation, perceived health benefits, and a strong interest in nutrition and cooking education. For outcome evaluation, chi-square tests of association results showed statistically significant improvements in several key indicators, including food security, ability to afford balanced meals, hunger, mental health, and body mass index (BMI). Findings suggest that Appalachian Farmacy positively impacted food access, dietary behaviors, and health outcomes among participants in a rural setting. These results underscore the value of community-based nutrition incentive models and highlight the need for future adaptations to enhance accessibility, sustain engagement, and scale impact across rural populations.