key: cord-0759280-38fq2x15 authors: Blair, Cindy K.; Harding, Elizabeth M.; Adsul, Prajakta; Moran, Sara; Guest, Dolores; Clough, Kathy; Sussman, Andrew L.; Duff, Dorothy; Cook, Linda S.; Rodman, Joseph; Dayao, Zoneddy; Brown-Glaberman, Ursa; King, Towela V.; Pankratz, V. Shane; Servin, Eduardo; Davis, Sally; Demark-Wahnefried, Wendy title: Southwest Harvest for Health: Adapting a mentored vegetable gardening intervention for cancer survivors in the southwest date: 2021-02-11 journal: Contemp Clin Trials Commun DOI: 10.1016/j.conctc.2021.100741 sha: d58979d90e32a1d3c3897ec019473cc3f1b1e75d doc_id: 759280 cord_uid: 38fq2x15 Few diet and physical activity evidence-based interventions have been routinely used in community settings to achieve population health outcomes. Adapting interventions to fit the implementation context is important to achieve the desired results. Harvest for Health is a home-based vegetable gardening intervention that pairs cancer survivors with certified Master Gardeners from the Cooperative Extension Service with the ultimate goal of increasing vegetable consumption and physical activity, and improving physical functioning and health-related quality-of-life. Harvest for Health has potential for widespread dissemination since Master Gardener Programs exist throughout the United States. However, state- and population-specific adaptations may be needed to improve intervention adoption by other Master Gardener Programs. Our primary objective was to adapt this evidence-informed intervention that was initially incepted in Alabama, for the drastically different climate and growing conditions of New Mexico using a recommended adaptation framework. Our secondary objective was to develop a study protocol to support a pilot test of the adapted intervention, Southwest Harvest for Health. The adaptation phase is a critical first step towards widespread dissemination, implementation, and scale-out of an evidence-based intervention. This paper describes the adaptation process and outcomes, and the resulting protocol for the ongoing pilot study that is currently following 30 cancer survivors and their paired Extension Master Gardener mentors. By 2022, there will be 18 million cancer survivors living in the U.S [1] . Cancer survivors are at increased risk for treatment-related comorbidity, including cardiovascular disease, diabetes, osteoporosis, and reduced quality of life (QOL) [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . A healthful diet and regular physical activity may help prevent, delay, or mitigate, poor health outcomes associated with cancer and its treatment. While a cancer diagnosis can lead patients to reconsider their lifestyle behaviors, a large proportion of cancer survivors do not meet the recommendations for a healthy lifestyle that includes ample amounts of high-nutrient foods, such as vegetables, and regular physical activity [12] [13] [14] [15] . Many diet and physical activity interventions have been shown to be efficacious in cancer survivors [16] [17] [18] . However, few interventions have been successfully translated into practice, i.e., routinely used in community settings to achieve population health outcomes [18] [19] [20] . Emerging data suggests that vegetable gardening may provide an integrated approach to promote a healthful diet, physical activity, stress relief, and psychosocial well-being [21] [22] [23] [24] [25] [26] [27] [28] . Furthermore, gardening has great potential for long-term engagement given that it provides access to seasonal fresh produce and exposure to a variety of gardening activities and tasks, which may prevent satiation common with other diet and exercise programs [29] . Additionally, gardening provides continual behavioral cues since plants require regular care (watering, pest control) and attention (harvesting) [22] . Harvest for Health is a home-based, mentored vegetable gardening intervention for cancer survivors [21] [22] [23] 30] . Preliminary results suggest that this intervention increases vegetable consumption and physical activity, and improves physical functioning and health-related quality of life (hrQOL) [21] [22] [23] . To date, it has been tested among cancer survivors living in Alabama. Harvest for Health was designed with dissemination in mind. The gardening experts providing one-on-one mentorship to cancer survivors are part of an extant infrastructurethe Cooperative Extension Master Gardener Program [31, 32] . The Cooperative Extension Service, is the education and outreach arm of land-grant universities nationwide [32] . The Master Gardener Program is one of many educational outreach programs offered by the Extension, and exists in all states and territories of the United States, as well as some Canadian provinces and South Korea [31, 33] . Master Gardener volunteers are trained by land-grant university staff to provide research-based gardening education to the local community. These programs typically have widespread coverage throughout the state, thus serving both urban and rural communities. Depending upon the state, Master Gardeners typically complete 50-100 h of training, plus additional community service to become certified; moreover, 20-50 h of volunteer community service may be required each year to maintain active status. While community service is not required by all Master Gardener Programs, the original and defining purpose of the program is to provide volunteers to assist the Extension. The type of community service projects performed by Master Gardeners is dependent on the needs and interests of their communities. While there is potential for widespread dissemination of Harvest for Health through the Extension Master Gardener Program, evidence is needed for scaling out to an Extension in another state [34] . Scaling out refers to adapting and delivering evidence-based interventions to either new populations, new delivery systems, or both [34] . Evidence beyond the original trial(s) is needed to determine whether the core elements of the intervention can be delivered with fidelity and whether the new context is supportive of delivery of the intervention [34] . Since the Master Gardener Programs vary among states, and even by counties within a state, further study is necessary to understand how to effectively scale out the Harvest for Health intervention from one state to another [35] [36] [37] . Differences between programs might include availability of staffing or financial resources, leadership structure, or organizational culture, including priorities and goals [37] [38] [39] . Thus, state-and population-specific adaptations may be needed to improve intervention adoption by other Master Gardener Programs throughout the Extension [35, 36] . Adapting these interventions to fit the implementation context is important to achieve the desired impact [40] [41] [42] . Building on the promising results of Harvest for Health, the first objective of the current study was to adapt the intervention for the local context of New Mexico, i.e., the physical, social, and cultural environment, and for delivery by the New Mexico Extension Master Gardner Program. Answering the call for a proactive, systematic approach to adaptation [40, 42, 43] , we used the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) by Stirman and colleagues to guide the adaptation process, including detailed documentation of adaptations. Our second objective was to develop a study protocol to support a pilot test of the adapted intervention, Southwest Harvest for Health. The current paper describes the adaptation process and outcomes, and the resulting study protocol for the ongoing pilot study that is currently following 30 cancer survivors and their paired Extension Master Gardener mentors. The primary objective of this study was to systematically identify, document, and test the adaptations needed for the Harvest for Health intervention to be successfully implemented in New Mexico, while maintaining fidelity to the original intervention. Fidelity refers to the degree to which an intervention is implemented as intended [44] , often focusing on the core components of the intervention believed to be essential for producing the desired outcomes [42, 45] . Adaptation refers to the degree to which an intervention is modified to improve the fit to the local population or context [44] . Balancing fidelity and adaptation requires the identification and preservation of the core components of the original intervention [44, 46] . For Harvest for Health, the primary core component is the one-on-one mentoring of the cancer survivor by a certified Master Gardener. Another core component includes the provision of gardening tools, supplies, and an assortment of plants and seeds for the cancer survivor to establish a home vegetable garden. We began by following the intervention adaptation steps identified by Escoffery et al. who summarized common steps from existing frameworks for adapting evidence-based interventions [47] . The eleven key adaptation steps include: 1) assess the community, which refers both to the target population and the capacity of the community organization to implement the intervention; 2) understand the intervention, including the behavioral theory behind the intervention and the core elements of the intervention; 3) select the intervention; 4) consult with experts, including developers of the original intervention; 5) consult with stakeholders from the beginning and throughout; identify program champions; 6) decide what needs adaptation, such as program structure, content, delivery methods, while retaining fidelity to the core elements; 7) adapt the original program (or intervention); 8) select and train staff to ensure quality implementation; 9) test the adapted materials via readability tests or pilot study; 10) develop implementation plan and test the adapted intervention; and 11) evaluate the process and outcomes of the adapted intervention, and document the adaptation process [47] . Specific details about how this process was applied to this study are included in Table 1 . As stated, the adaptation process, including detailed documentation of adaptations, was guided by FRAME [41] which includes the following elements for documenting adaptations: 1) point during the implementation process the modification occurred (e.g., pre-implementation, implementation, scale-up/scale-out); 2) whether the modification was planned (proactive) or unplanned (reactive); 3) who participated in the decision to modify (e.g., researcher, community members, intervention team); 4) what was modified (e.g., content, context, training and evaluation); 5) for whom the modification was made (e.g., individual, organization, network system); 6) nature of content modification (e.g., adding or removing intervention elements; shortening or lengthening intervention); 7) whether modification was fidelity consistent or inconsistent regarding preservation of core elements of the intervention; 8) reasons for the modification, including the goal (e.g., reduce costs, increase reach/engagement) and contextual factors that influenced the decision (e.g., available resources, cultural norms) [40, 41, 48] . The FRAME Coding Manual and checklist were used to document each adaptation [41, 49] . Per step 9 in the adaptation process described above, we adapted materials and the intervention to be pilot tested in a new population, utilizing a new delivery system (New Mexico Extension). This section describes the resulting protocol for the ongoing pilot study. The study protocol was approved by the Human Research Review Committee at the University of New Mexico Health Sciences Center. The trial was registered at ClinicalTrials.gov on January 31, 2020 (Identifier NCT04251299). The pilot study was designed as a single-arm trial. The study is currently being conducted in New Mexico, a large and sparsely populated state, ranking 5th in size and 6th among the lowest population density states [50] . For logistical efficiency (home visits to collect data), the study was restricted to two adjacent counties in New Mexicoone of which is home to the state's comprehensive cancer center. This is a home-based intervention, whereby participants establish and maintain a vegetable garden at their home. Similar to the original Harvest for Health study [21] [22] [23] 30] , the current pilot study is a community-based, partnership between the University of New Mexico (UNM) and the Albuquerque Area Extension Master Gardener Program from New Mexico State University's Cooperative Extension Service [51] [52] [53] . To adapt and pilot the intervention in NM, we specifically partnered with two Master Gardener Programs: Bernalillo County (the largest county in the state with the largest Master Gardener Program, as well as the location of the University of New Mexico research team) and nearby Sandoval County (a rural county with a smaller Master Gardener Program). In NM, community volunteer opportunities for Master Gardeners must be approved by each program's Board of Directors. Once approved, a volunteer Master Gardener Coordinator is assigned to oversee and provide support for Master Gardeners who select the project for their volunteer experience. Master Gardeners select one or more of the approved community volunteer projects each year to maintain active status. For this pilot study, the county extension agents and project coordinators from the Master Gardener Program were responsible for recruiting, training, and supporting the Master Gardeners who volunteered to be mentors. Interns who were still in training were paired with a veteran Master Gardener; a veteran Master Gardener attends continuing education classes each year in addition to their volunteer Table 1 Key steps for the adaptation of harvest for health to southwest harvest for health. •We are working with our consultants (original developers) to ensure that the adapted procedures and materials maintain the accuracy of the originals •We are using the FRAME adaptation framework to guide the systematic identification and documentation of adaptations (See Table 3 for a description of adaptations) 8. Train staff •The Master Gardener Leadership team is primarily responsible for recruiting Master Gardeners into the study, and providing support during the study. •A training meeting was held with the Master Gardeners service. After the cancer survivors were recruited, they were paired with a certified Master Gardener based on proximity (typically <10 miles). The UNM Study Team was responsible for enrolling, monitoring, and collecting data from study participants (cancer survivors). Recruitment flyers were distributed in community locations such as cancer survivor groups and community centers in the two counties included in the pilot study. Additionally, oncologists, physicians, and nurse navigators referred patients (cancer survivors) to the study by giving them a study flyer. Interested individuals contacted study staff by telephone or email. Screenings occurred over the telephone. The inclusion criteria included: (1) Aged 50 years or older; (2) Diagnosed with an invasive, nonmetastatic cancer; metastatic cancer patients were eligible with MD approval; (3) Community dwelling and not residing in a skilled nursing or assisted living facility (must be able to tend their garden and cook their own meals); (4) Consumed fewer than 5 fruit and vegetable servings per day and spent <150 min per week in moderate-to-vigorous physical activity; (5) Resided in a location that could accommodate a 4 ′ x 8' raised garden bed or 4 (29 ′′ x 14") garden containers, and have adequate (at least 6 h) of sunlight per day and access to running water; (6) Able to read, speak, and understand English (future larger trial will include Spanish-speaking participants); and (7) Able to participate in the 9-month intervention (all three seasonal gardens; from March through mid-November 2020). Exclusion criteria included: (1) Told by a physician to limit physical activity or having a pre-existing medical condition (s) that substantially limited daily light-intensity physical activity (i.e. activities of daily living: bending, stooping, walking, etc.) that would preclude gardening; and (2) Existing or recent (within the past year) experience with vegetable gardening or living with someone who has had a successful vegetable garden within the past year. After written informed consent was obtained, a home visit was scheduled to collect baseline data. The initial Harvest for Health intervention was developed at the University of Alabama at Birmingham in partnership with the Alabama Cooperative Extension Service. The intervention uses the Social Cognitive Theory (SCT) [54] [55] [56] and Social Ecological Model (SEM) [57, 58] as theoretical frameworks to promote behavior change [22, 30] . The Master Gardeners serve as role models and mentors to promote gardening self-efficacy, provide incremental guidance to participants throughout the intervention, provide reinforcement and encouragement as needed, and strategize to overcome barriers. Moreover, healthy lifestyle behaviors, as well as quality of life, also could be influenced by the relationships between the survivor and their social (e.g. support from Master Gardener mentor) and physical (e.g. outdoor environment including sunshine, fresh air, etc.) environments according to the Social Ecological Model. Harvest for Health [21] [22] [23] 30] pairs each cancer survivor with a certified Master Gardener from the Extension. The participant/Master Gardener dyads work together to plan, plant, maintain, and harvest three seasonal gardens at the participants' homes. Participants receive gardening supplies, plants and seeds, and print materials on gardening safety, health, and nutrition. However, most of the gardening knowledge is imparted by working with their assigned Master Gardener mentor. The expectation is that the dyads communicate every two weeks throughout the intervention, alternating between home visits and telephone or email. The components of the adapted intervention -Southwest Harvest for Healthare included in Table 2 . 2.2.5.1. Primary outcomes. The primary outcomes of this ongoing pilot study include the implementation outcomes of acceptability, Shortened to 9-month intervention due to more severe winter weather; still able to include 3 seasonal gardens (just shorter in duration) The kick-off event of the intervention where participants meet their Master Gardener mentor, exchange contact information and best days/times/preferences (e.g., email, phone) to communicate. Same, but we also provided smaller gardening supplies at this event (rather than delivery with larger supplies) to increase engagement. Notebook & Garden Journal: The notebook includes the following: Supplies needed to begin a home vegetable garden are provided to the participants (delivered to their homes by Home Depotcommon throughout AL). These include: soil/potting mix, plants, seeds, and mulch to support either four containerstyle garden boxes (20.5 by 24.5 inches; can be used to garden on balconies, patios or decks) or 1 raised bed garden (4 by 8 foot; equivalent square footage). An assortment of gardening tools is also provided (e.g., hand tools, hose, tomato cages, watering can). These supplies are provided free of charge. Participants are allowed to keep their supplies and tools at the end of the study to promote continued gardening. First, a team of NM Master gardeners reviewed the list of supplies and tools used in AL. Despite alternative options for vendors, the decision was made to purchase through Home Depot for logistical efficiency (adequate supply, delivery, one-stop shopping), especially for scaling-up across the state. Minor modifications were made to the list (replaced more expensive tomato cages with bamboo stakes and twine; added a water meter). Seeds were provided by the local Extension office seed library. We were unable to schedule home deliveries of the larger gardening supplies prior to the statewide stayat-home order (March 2020). Instead, a single-site distribution center was established, and (continued on next page) C.K. Blair et al. appropriateness, and feasibility [59] . For Southwest Harvest for Health, acceptability is the perception of the Master Gardeners that the intervention is appealing. Appropriateness is the fit or relevance of the intervention for the Master Gardener Program. Feasibility is the extent to which the mentored gardening intervention can be successfully delivered by the Master Gardeners. These outcomes will be assessed upon completion of the study using quantitative data from surveys, and qualitative data from individual interviews. As with most pilot studies, the Southwest Harvest for Health study was not powered to detect clinically meaningful nor significant changes in measures of diet, physical activity, physical performance, and quality of life. However, the pre-post changes will be used to generate estimates for a future, larger trial. Home visits to assess secondary study outcomes occur three times over the study period: baseline (within one month prior to intervention start), midintervention (around 6 months) and post-intervention (at 10 months). At baseline, two members of the study team visited the participant at their residence to assess the participant's health status. Prior to the home visit, participants were mailed questionnaires to be completed, and then collected by study investigators during the home visit. Verification of adequate space, sunlight, and running water to support a vegetable garden occurred at the baseline home visit. Due to COVID-19, follow-up home visits were replaced with telephone, and mail or digital surveys. The following data are collected: A semi-structured debriefing telephone call is made to study participants after the intervention to assess satisfaction, gardening fidelity, future gardening plans, and suggestions for the study. A "bounty party" was planned for the end of the study, the Albuquerque Area Extension Master Gardeners and study team were to host an event that would allow participants an opportunity to "show-off" and share their vegetables and herbs from their gardens. Due to the ongoing COVID-19 pandemic, including the recent surge in cases, the "bounty party" was cancelled. Instead, quantitative and qualitative data about the intervention will be collected from both study participants and their volunteer Master Gardeners. a These components are considered the core components of the intervention that are critical for achieving the health outcomes, and thus, should not be modified in order to maintain fidelity to the original intervention. gardening intervention) [60] . Questions include frequency (ranging from never to multiple times per day) and amount (ranging from none to more than two cups) for selected foods. the Godin Leisure Time Physical Activity Questionnaire to assess selfreported leisure-time physical activity. It includes type, frequency, and duration of activities at three intensity levels (light/mild, moderate, and vigorous) [61] [62] [63] . The PACE Adult Sedentary Behavior Questionnaire is used to estimate self-reported sedentary activities during a typical weekday and during a typical weekend. Response items range from none to 6 or more hours per day for nine common activities (e.g., watching television, using a computer, reading, etc.) [64] . Objective measures of both physical activity and sedentary behavior are measured using accelerometry. Participants are asked to wear the activPAL3, a small, thin device (like a patch) that is worn on the mid-thigh (day and overnight) for 7 days at the beginning, at 6 months, and at the end of the study [65] [66] [67] [68] . Verbal and written Instructions for applying and removing the monitor are provided to the participant. Comorbidity Index is used to assess the number of chronic medical conditions and symptoms and their functional impact [78] . The survey includes 42 conditions and symptoms (not including cancer), and whether each condition/symptom interferes with activities (not at all, a little, a great deal) [78] . 8. Perceived Social Support: The Social Provision Scale is used to assess the psychosocial benefits of gardening. It includes six subscales including: emotional support or attachment, social integration, opportunity for nurturance, reassurance of worth, reliable alliance, and guidance [79] . Several gardening studies have reported enhanced self-esteem, increased independence, and increased zest for life [80, 81] . 9. Mediators: Community-Level: Participants will assess their local environment for support of vegetable gardening considering the following factors: 1) availability of garden stores; 2) presence of pests/wildlife (i.e., insects, deer, coyotes); 3) neighborhood covenants that impose landscaping restrictions; and 4) sense of belonging with other gardeners in local community [30] . Interpersonal: We will use the Social Support & Eating Habits & Exercise Surveys adapted for gardening (12 items) [30, 82] . Individual: This assessment will measure the cancer survivors' self-efficacy (survivors' beliefs in their ability to maintain a successful vegetable garden; 3-items). A formal sample size calculation was not performed for this study. With our targeted sample size of 30 participants (and allowing for 20% attrition), we will be able to estimate population parameters to within plus or minus 0.42 standard deviations of truth with 95% confidence in our analyses of secondary outcomes. The resulting estimated effect sizes will provide critical preliminary information that will enable the design of a subsequent, larger study. Baseline descriptive characteristics (mean ± SD, number (%)) are presented to characterize the enrolled study population (cancer survivors). Upon completion of the pilot study, we will evaluate pre-post intervention change for the health outcomes (vegetable servings per day, physical activity, QOL, etc.). Preliminary evidence of the acceptability, appropriateness, and feasibility of the adapted vegetable gardening intervention among Master Gardeners will be assessed thorough the collection of detailed process data. Quantitative surveys will be distributed at the end of the intervention. Additionally, one-on-one interviews will be conducted with a sample of Master Gardeners. Additionally, we will assess the intervention outcomes of accrual, retention, adherence, and adverse events. The digital audio files from the telephone or Zoom interviews will be transcribed verbatim. Transcripts will be uploaded into NVivo 10 Qualitative Data Management and Analysis software (QSR International) and analyzed to identify key themes and codes. These themes will be summarized, reviewed, and interpreted by the study team, and ultimately will be used to inform the future trial. Illustrative quotes for each theme will be identified. Table 3 describes the components of the original Harvest for Health intervention as well as the adaptations to the intervention, prior to and during implementation in New Mexico. A summary of how we applied the FRAME framework for documenting adaptations has been divided into two categories: pre-and during the COVID-19 pandemic. Prior to COVID-19, the adaptations: 1) occurred during the pre-implementation/ planning stage; 2) were proactive/planned; 3) resulted from discussions and agreement between the Master Gardener Leadership Team and the UNM study team; 4) included content and contextual modifications; 5) were made primarily at the individual level (study participant); 6) were primarily tailoring, tweaking, or refining content; 7) were fidelity consistent; and 8) were made to improve feasibility, increase engagement, or to better fit the local context (e.g., climate, growing conditions). Additional modifications were made due to COVID-19, which: 1) occurred during implementation; 2) were proactive/planned; 3) were jointly decided by the Master Gardener Leadership and UNM study teams; 4) included contextual modifications; 5) were made primarily at the individual level (both study participants and Master Gardeners); 6) N/Aadaptations are contextual; 7) were both fidelity consistent (pickup vs. delivery of gardening tools and supplies) and inconsistent (suspension of monthly home visits); and 8) were made to allow us to start the intervention and keep it going, while maintaining everyone's safety during the COVID-19 pandemic. Enrollment opened on January 2, 2020 and was scheduled to close on March 2, 2020 in order to complete the baseline assessments prior to the Meet & Greet Event (scheduled for March 5th). The first study participant was enrolled on January 17th. A total of 42 individuals expressed interest in the study (Fig. 1 ). Of these, 10 did not meet eligibility criteria and two were unable to be screened before the enrollment period closed. Thus, 30 individuals were enrolled in the study. Enrollment was completed on February 25, 2020. Table 3 provides the baseline characteristics of the enrolled study participants. The mean age at study enrollment was 68 years (range 50-83), 70% of participants are female, 73% are non-Hispanic White, and 57% have graduated from college. The majority of participants reported three or more comorbidities (63%; mean of 3.2 ± 2.0) and reported their general health as good (60%). Over one-third are survivors of breast cancer, and the remainder have been diagnosed with prostate (20%), lung (13%), and a variety of other cancer types (30%). At baseline, participants reported an average of 1.8 ± 1.7, and 2.6 ± 1.5 servings per day of fruits and vegetables, respectively. Nearly four times as many minutes per week were spent in light-intensity compared to moderate-intensity self-reported physical activity. While many lifestyle interventions conducted among cancer survivors have demonstrated efficacy in improving diet quality, physical activity, or quality of life, the long-term durability of these interventions remains unanswered, and the potential for widespread dissemination for many of these center-and clinic-based interventions is limited. Harvest for Health represents an integrated strategy to increase both vegetable consumption and physical activity, and improve quality of life among cancer survivors. Designed with widespread dissemination in mind, the Harvest for Health intervention utilizes the infrastructure of the nationwide Extension Master Gardener Program [31, 32] . The current study has adapted the Harvest for Health intervention to the drastically different climate and growing conditions of New Mexico using a recommended adaptation process and framework [40, 41, 47] . This process led to the development of a study protocol to pilot test the adapted intervention, Southwest Harvest for Health, which was successfully launched as the COVID-19 pandemic was emerging. Upon completion, the pilot study will provide important information on acceptability, appropriateness, and feasibility among Master Gardeners from the New Mexico Extension. Understanding the local implementation context is essential for identifying barriers, and implementation strategies to overcome these barriers, prior to scaling-out to and evaluating effectiveness in a new population using a new delivery system. As previously mentioned, the majority of adaptations that we made to Harvest for Health were related to context, specifically the vastly different climate and growing conditions of the Southwest. However, New Mexico also includes a multi-cultural population that differs substantially from the original population in Alabama. Thus, further adaptations, especially cultural adaptations, may be needed given that our ongoing pilot study recruited a convenience sample that was primarily (73%) non-Hispanic White, and only 20% Hispanic White (the remaining 7% represent other racial groups that account for less than 5% of the New Mexico population). Based on cancer case counts by race-ethnicity for the two counties included in the study [83] , approximately 62%, 34%, and 4% of the cases are non-Hispanic White, Hispanic, and American Indian (the three largest racial-ethnic groups in New Mexico). Therefore, in future studies, work will be needed to ensure that our recruitment efforts reach out and increase awareness of this intervention among Hispanic and American Indian populations. Ongoing cultural adaptations may be needed to improve the relevance, acceptability, or effectiveness of Harvest for Health in this population. As with numerous research studies, the COVID-19 pandemic has caused several unexpected challenges for the Southwest Harvest for Health intervention. In addition to the proactive adaptations made during the pre-implementation/planning stage, we had to make several additional adaptations during implementation to allow the intervention to continue. These additional adaptations, decided jointly by the research and intervention delivery teams, were still planned, proactive (e.g., replacing monthly home visits with an extra telephone call). The planned evaluation at the end of the intervention will determine whether unplanned, reactive adaptations were made by individual Master Gardeners delivering the intervention. When asked what type of impact COVID-19 was having on the study, 91% of Master Gardeners indicated a negative impact (9% no impact; 0% positive), with a unanimous explanation that their preference was to meet with their participant in person and to see their garden (i.e., the monthly home visit). In contrast, when asked the same question, 47% of the cancer survivors indicated a negative impact (with the same reason as Master Gardeners), with 37% indicating no impact. Despite these modifications, participants were excited to receive their gardening supplies, establish a vegetable garden, and to be receiving guidance, albeit remotely, from their Master Gardener mentor. The current study represents a concerted and planful effort to grow the Harvest for Health intervention in order to reach a greater number of cancer survivors. The adaptation phase is a critical first step towards widespread dissemination, implementation, and scale-up of an evidence-based intervention. Results from this pilot study will be used to inform a hybrid effectiveness-implementation study to identify implementation strategies to increase the adoption and successful implementation of this intervention throughout New Mexico, and perhaps even further beyond to states with comparable environments, populations, and services. This research was supported by the University of New Mexico (UNM) Comprehensive Cancer Center Research Project Support Pilot Mechanism, the Behavioral Measurement and Population Sciences Shared Resource and the Biostatistics Shared Resource (NIH/NCI: P30CA118100). CKB is currently supported by an NIH/NCI K07 grant CA215937. 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We also thank the Extension Master Gardeners who graciously give of their time and expertise. We are especially grateful for everyone's patience and understanding as we have had to make several modifications to the study due to the COVID-19 pandemic.