"You Guys Really Care About Me…": a Qualitative Exploration of a Produce Prescription Program in Safety Net Clinics

Rationale and design of the KP ENRICH trial: A food is medicine intervention in low-income high-risk adults with diabetes within Kaiser Permanente

BACKGROUND

Food insecurity is associated with poor glycemic control and increased risk for diabetes-related complications. The clinical benefit of addressing these challenges through a medically supportive grocery prescription (GRx) program in patients with type 2 diabetes mellitus (T2D) remains unclear. We report the aims and design of a randomized clinical trial to evaluate the effectiveness of a 6-month GRx intervention on hemoglobin A1c (HbA1c) levels among low-income adults with T2D.

METHODS

The Kaiser Permanente Evaluating Nutritional Interventions in Food-Insecure High-Risk Adults (KP ENRICH) Study is a pragmatic randomized trial enrolling 1100 participants within Kaiser Permanente Northern California and Southern California, two integrated health care delivery systems serving >9 million members. Medicaid-insured adults with T2D and baseline HbA1c ≥7.5% will be randomized at a 1:1 ratio to either GRx, delivered as $100 per month for select items from among a curated list of healthful food groups in an online grocery ordering and home-delivery platform along with biweekly digital nutrition educational materials, or control, consisting of free membership and deliveries from the online grocery platform but without curated food groups or purchasing dollars. The primary outcome is 6-month change in HbA1c. Secondary outcomes include 12-month change in HbA1c, and 6- and 12-month change in medical resource utilization, food security, nutrition security, dietary habits, diabetes-related quality of life, and dietary self-efficacy.

CONCLUSIONS

The results of this large randomized clinical trial of GRx will help inform future policy and health system-based initiatives to improve food and nutrition security, disease management, and health equity among patients with T2D.

Implementation of Food is Medicine Programs in Healthcare Settings: A Narrative Review

Food is Medicine (FIM) programs to improve the accessibility of fruits and vegetables (FVs) or other healthy foods among patients with low income and diet-related chronic diseases are promising to improve food and nutrition security in the United States (US). However, FIM programs are relatively new and implementation guidance for healthcare settings using an implementation science lens is lacking. We used a narrative review to describe the evidence base on barriers and facilitators to FIM program integration in US healthcare settings following the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework. Evidence surrounding the EPIS Inner Context was a focus, including constructs Leadership, Organizational Characteristics, Quality and Fidelity Monitoring and Support, Organizational Staffing Processes, and Individual Characteristics. Peer-reviewed and grey literature about barriers and facilitators to FIM programs were of interest, defined as programs that screen and refer eligible patients with diet-related chronic disease experiencing food insecurity to healthy, unprepared foods. Thirty-one sources were included in the narrative review, including 22 peer-reviewed articles, four reports, four toolkits, and one thesis. Twenty-eight sources (90%) described EPIS Inner Context facilitators and 26 sources (84%) described FIM program barriers. The most common barriers and facilitators to FIM programs were regarding Quality and Fidelity Monitoring and Support (e.g., use of electronic medical records for tracking and evaluation, strategies to support implementation) and Organizational Staffing Processes (e.g., clear delineation of staff roles and capacity); although, barriers and facilitators to FIM programs were identified among all EPIS Inner Context constructs. We synthesized barriers and facilitators to create an EPIS-informed implementation checklist for healthcare settings for use among healthcare organizations/providers, partner organizations, and technical assistance personnel. We discuss future directions to align FIM efforts with implementation science terminology and theories, models, and frameworks to improve the implementation evidence base and support FIM researchers and practitioners.

Local Food System Approaches to Address Food and Nutrition Security among Low-Income Populations: A Systematic Review

Food and nutrition insecurity disproportionately impact low-income households in the United States, contributing to higher rates of chronic diseases among this population. Addressing this challenge is complex because of various factors affecting the availability and accessibility of nutritious food. Short value chain (SVC) models, informally known as local food systems, offer a systemic approach that aims to optimize resources and align values throughout and beyond the food supply chain. Although specific SVC interventions, such as farmers markets, have been studied individually, a comprehensive review of SVC models was pursued to evaluate their relative impact on food security, fruit and vegetable intake, diet quality, health-related markers, and barriers and facilitators to participation among low-income households. Our systematic literature search identified 37 articles representing 34 studies from 2000-2020. Quantitative, qualitative, and mixed-method studies revealed that farmers market interventions had been evaluated more extensively than other SVC models (i.e., produce prescription programs, community-supported agriculture, mobile markets, food hubs, farm stands, and farm-to-school). Fruit and vegetable intake was the most measured outcome; other outcomes were less explored or not measured at all. Qualitative insights highlighted common barriers to SVC use, such as lack of program awareness, limited accessibility, and cultural incongruence, whereas facilitators included health-promoting environments, community cohesion, financial incentives, and high-quality produce. Social marketing and dynamic nutrition education appeared to yield positive program outcomes. Financial incentives were used in many studies, warranting further investigation into optimal amounts across varying environmental contexts. SVC models are increasingly germane to national goals across the agriculture, social, and health care sectors. This review advances the understanding of key knowledge gaps related to their implementation and impact; it emphasizes the need for research to analyze SVC potential comprehensively across the rural-urban continuum and among diverse communities through long-term studies of measurable health impact and mixed-method studies investigating implementation best practices. This trial was registered at PROSPERO as CRD42020206532.

Clients' experiences and satisfaction with produce prescription programs in California: a qualitative evaluation to inform person-centered and respectful program models

Background

Produce prescription programs have strong potential to improve food security, fruit and vegetable consumption, and health across the life course. Understanding clients' experiences and satisfaction with produce prescription programs is critical for evaluating the person-centeredness and quality of these programs. The objectives of this study were to (1) describe client experiences and satisfaction with produce prescription programs, with an emphasis on the extent to which they felt they were treated with respect and dignity, and (2) identify recommendations for improving client experiences.

Methods

We conducted four focus group discussions with clients of produce prescription programs in two Federally Qualified Health Centers in California. We used a modified framework analysis approach and organized participants' experiences with programs into themes.

Results

Three themes captured participants' program experiences. First, respectful produce prescription programming encompassed interactions with individuals delivering the programs that felt respectful (e.g., program staff showing they cared about participants' health and offering timely assistance with financial incentives) and disrespectful (e.g., not receiving prompt responses to questions about incentives), as well as aspects of program design perceived to be respectful (e.g., provision of gift cards as financial incentives, which offered privacy when purchasing produce). Second, having autonomy to use gift cards to choose their preferred fresh fruits and vegetables was viewed as a positive experience, though participants desired greater autonomy to shop at stores other than the program designated stores. Third, participants frequently discussed program usability, with some reporting that joining the programs and using the cards was easy, and others describing difficulties activating cards and using them at stores due to cashiers' lack of awareness of the programs. Overall, participants were highly satisfied with the programs. To improve client experiences, they recommended increasing privacy (e.g., by educating cashiers on the programs so that clients do not need to explain in public what the card is for) and autonomy (e.g., allowing cards to be used at other chain or local stores).

Discussion

Our findings inform efforts to make produce prescription programs more person-centered and respectful, which in turn may increase program demand, engagement, and impact.

Exploring the prospective acceptability of a healthy food incentive program from the perspective of people with type 2 diabetes and experiences of household food insecurity in Alberta, Canada

OBJECTIVE

FoodRx is a 12-month healthy food prescription incentive program for people with type 2 diabetes (T2DM) and experiences of household food insecurity. In this study, we aimed to explore potential users' prospective acceptability (acceptability prior to program use) of the design and delivery of the FoodRx incentive and identify factors influencing prospective acceptability.

DESIGN

We used a qualitative descriptive approach and purposive sampling to recruit individuals who were interested or uninterested in using the FoodRx incentive. Semi-structured interviews were guided by the theoretical framework of acceptability, and corresponding interview transcripts were analysed using differential qualitative analysis guided by the socioecological model.

SETTING

Individuals living in Alberta, Canada.

PARTICIPANTS

In total, fifteen adults with T2DM and experiences of household food insecurity.

RESULTS

People who were interested in using the FoodRx incentive (n 10) perceived it to be more acceptable than those who were uninterested (n 5). We identified four themes that captured factors that influenced users' prospective acceptability: (i) participants' confidence, views and beliefs of FoodRx design and delivery and its future use (intrapersonal), (ii) the shopping routines and roles of individuals in participants' social networks (interpersonal), (iii) access to and experience with food retail outlets (community), and (iv) income and food access support to cope with the cost of living (policy).

CONCLUSION

Future healthy food prescription programs should consider how factors at all levels of the socioecological model influence program acceptability and use these data to inform program design and delivery.

Healthcare-based food assistance programmes in the United States: a scoping review and typology

This scoping review aimed to identify the breadth of healthcare-based food assistance programmes in the United States and organize them into a typology of programmes to provide implementation guidance to aspiring food assistance programmers in healthcare settings. We searched PubMed, Cochrane, and CINAHL databases for peer-reviewed articles published between 1 January 2010 and 31 December 2021, and mined reference lists. We used content analysis to extract programmatic details from each intervention and to qualitatively analyse intervention components to develop a typology for healthcare institutions in the United States. Eligible articles included descriptions of patient populations served and programmatic details. Articles were not required to include formal evaluations for inclusion in this scoping review. Our search resulted in 8706 abstracts, which yielded forty-three articles from thirty-five interventions. We identified three distinct programme types: direct food provision, referral, and voucher programmes. Programme type was influenced by programme goals, logistical considerations, such as staffing, food storage or refrigeration space, and existence of willing partner CBOs. Food provision programmes (n 13) were frequently permanent and leveraged partnerships with community-based organisations (CBOs) that provide food. Referral programmes (n 8) connected patients to CBOs for federal or local food assistance enrollment. Voucher programmes (n 14) prioritised provision of fruits and vegetables (n 10) and relied on a variety of clinic staff to refer patients to months-long programmes. Healthcare-based implementers can use this typology to design and maintain programmes that align with the needs of their sites and patient populations.

"Something Fun to Look Forward to": Lessons From Implementing the Prescription for Health Farmers' Market Initiative in Rural Upper Michigan

Fruit and vegetable (FV) prescription programs are an increasingly popular community-based approach to addressing food insecurity and improving nutrition by connecting local health care and food systems. The Prescription for Health farmers' market FV prescription program was piloted in a rural, low-access low-income Michigan community in 2017. The program enrolled 33 adult participants with chronic disease and provided weekly farmers' market FV vouchers, educational nutrition handouts, and seasonal healthy recipes over 10 weeks. Weight, blood pressure, and the following self-rated variables were assessed pre- and post program: dietary habits, food literacy, physical health, and mental health. While most metrics remained generally unchanged, one of the strongest findings from our data included significant improvement in quality of life. Increased social interaction as a result of the attending the farmers' market was a prominent theme from informal open-ended participant feedback. Given the ongoing public health crisis of loneliness and social isolation, this finding led us to consider the farmers' market as an avenue for creating opportunities for meaningful social connection among participants and farmers. To this end, we discuss health outcomes of the Prescription for Health pilot program, reflect on unique aspects of implementing this program in a rural area, and explore future opportunities for farmers' market prescription programs as an innovative form of nature-based social prescribing.

Client experience of food assistance programs among adults in the United States: a qualitative evidence synthesis protocol

Introduction

Policymakers, health practitioners, and other key partners are increasingly focused on ensuring that clients of food assistance programs have positive experiences, a key aspect of high-quality programming. The objectives of this review are to describe the experiences of clients participating in food assistance programs in the United States (US) and to identify ways that these programs promote or hinder positive experiences.

Methods and analysis

We will conduct a qualitative evidence synthesis with partners from food security organizations and community members. Peer-reviewed literature will be systematically searched in Scopus, CINAHL, and AGRICOLA. To identify grey literature, we will use Google's programmable search engine. This review will consider sources that present results of primary qualitative studies that focus on at least one food assistance program in the US and explore the perspectives of adult clients. Only sources published in English or Spanish from 2007 onward will be included. Multiple reviewers will screen articles for inclusion and extract data from articles that meet the inclusion criteria, using a structured data extraction tool. Thematic synthesis or meta-ethnography may be appropriate approaches for synthesizing the extracted data. The final selection of synthesis method will be determined once the set of primary qualitative studies to be included in the review is complete and the type of data presented in these studies is known. We will assess the methodological quality of the included studies using the CASP (Critical Appraisal Skills Programme) tool for qualitative studies and assess the confidence in the review findings using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach.

Discussion

The findings of this review will inform the development of measures to assess client experience and quality improvement efforts.

Produce Prescriptions and Nutrition Education Improve Experiences and Perceptions of Farm Direct Settings in Adults With Low Income

OBJECTIVE

To examine Fruit and Vegetable Prescription (FVRx) Program participants' and nonparticipants' experiences and perceptions of farm direct (FD) settings.

DESIGN

Multiple-case study of adults with low income from 3 study groups: (1) FVRx intervention (produce prescription, nutrition education [NE], financial literacy education, health screening), (2) NE only, and (3) control (standard health care). Participant interviews with each group at baseline and 6 months.

SETTING

Supplemental Nutrition Assistance Program-Education (SNAP-Ed) eligible adults from 3 Georgia counties.

PARTICIPANTS

A total of 46 adults with ≥ 1 diet-related condition.

PHENOMENA OF INTEREST

Fruit and Vegetable Prescription Program participant and nonparticipant experiences and perceptions of FD settings.

ANALYSIS

Constant comparative methods and thematic analysis of qualitative interview data across groups.

FINDINGS

Two main themes emerged: (1) baseline FD setting experiences and perceptions and (2) divergent experiences and perceptions with FD settings postintervention. Participants across each group employed price-conscious food purchasing practices because of limited food budgets, limiting local food access. Combining produce prescription, NE, and farmers' market access enhanced FVRx participant associations with FD settings to reinforce motivation for accessing and purchasing fruits and vegetables beyond program participation.

CONCLUSIONS AND IMPLICATIONS

Fruit and Vegetable Prescription Programs reduce multiple barriers to participating in FD settings compared with NE or standard health care alone.

Food as Medicine Clinic: Early Results and Lessons Learned

INTRODUCTION

Hospital-based food pantries are commonly used to address food insecurity. However, few studies have examined the impact of these food pantries on patients with chronic health conditions. In this study, we sought to assess the effect of a hospital-based food pantry clinic on self-reported dietary changes, health outcomes, and resource utilization.

METHODS

This study included food insecure participants with suboptimally controlled congestive heart failure, hypertension, or diabetes who visited a Food as Medicine (FAM) clinic at an academic healthcare system between October 2018 and November 2019. The clinic provided a three-day supply of food for participants and their families up to two times per month for up to 12 months. Baseline, three-month, and six-month surveys were used to assess dietary behaviors, and electronic health record (EHR) data were used to assess health outcomes and utilization. Multivariable Poisson regression was used to explore variables associated with FAM clinic use.

RESULTS

At three months, participants self-reported improved dietary behaviors, including increased consumption of fruits and vegetables as snacks and an increased variety of fruits and vegetables consumed. There were no statistically significant changes in clinical or healthcare utilization measures, despite small absolute improvements in systolic blood pressure (SBP), hospitalizations, and emergency department (ED) visits. There was a weak association between FAM clinic visit frequency and changes in dietary behaviors.

CONCLUSION

Among patients with chronic diseases, the use of the FAM clinic was associated with improved self-reported dietary behaviors and a nonsignificant improvement in health outcomes and resource utilization.

Facilitators and Barriers to Patient Attendance at a Free Health Center Produce Market

INTRODUCTION

Patient participation in healthcare system‒sponsored efforts to address food insecurity varies widely. This mixed-methods study sought to understand the patient sociodemographic factors associated with and barriers and facilitators to the use of a monthly produce market held at Cambridge Health Alliance in partnership with The Greater Boston Food Bank.

METHODS

Baseline surveys (N=715) were conducted from February 2019 to March 2020 before market attendance, followed by 1-year follow-up surveys (n=514) and qualitative interviews (n=45). Robust Poisson regression estimated associations between sociodemographic characteristics and market attendance. Analyses were conducted from 2021 to 2022.

RESULTS

A total of 37.1% attended the market ≥1 time. Market attendance was associated with being aged 30-49 years (Risk Ratio (RR)=1.36, 95% CI=1.00, 1.86), having a monthly household income <$1,000 (RR=1.73, 95% CI=1.29, 2.32), identifying as Asian (RR=2.48, 95% CI=1.58, 3.89), having a preferred language for medical care other than English (RR=1.35, 95% CI=1.03, 1.76), being retired (RR=1.90, 95% CI=1.17, 3.08), and living in the city of the market's location (RR=1.36, 95% CI=1.12, 1.63). Barriers included limited time (28%), work conflict (23%), forgetfulness (23%), and not knowing market location/date (22%). Interviews revealed that accessibility barriers (e.g., limited market hours, transportation issues, competing demands, medical conditions, long lines) were obstacles to attendance, whereas access to novel, healthy foods motivated attendance.

CONCLUSIONS

Healthcare-based food distributions have the potential to reach patients with unmet food needs who cannot or would not access other forms of food assistance. Time constraints, physical limitations, and transportation challenges impact attendance; program modifications are necessary to improve accessibility.

A Produce Prescription Program in Eastern North Carolina Results in Increased Voucher Redemption Rates and Increased Fruit and Vegetable Intake among Participants

Few produce prescription programs have taken place in rural areas, in the context of existing public health programs. Thus, the purpose of this mixed-methods study was to examine voucher redemption rates, change in fruit and vegetable intake, and suggestions for improvement among participants enrolled in a produce prescription program occurring in existing public health programs throughout rural eastern North Carolina. We examined voucher redemption rates and conducted pre- (n = 125) and post-intervention surveys assessing fruit and vegetable intake. t-tests were used to examine changes in intake pre- versus post-intervention among 50 participants. Participants (n = 32) also completed a semi-structured, telephone interview. Qualitative data were thematically analyzed to determine potential improvements. The overall voucher redemption rate was 52%. There was a 0.29 (standard deviation = 0.91, p = 0.031) cup increase in self-reported fruit intake comparing post- to pre-intervention data. Qualitative analyses indicated that participants enjoyed the financial benefits of the program and wanted it to continue. The produce prescription program was successful in increasing self-reported fruit intake among participants. More research is needed to determine if changes in intake persist when measured objectively, and on best methods for the program’s financial sustainability.

Current Landscape of Produce Prescription Programs in the US

OBJECTIVE

To understand the design and implementation models of US produce prescription programs.

METHODS

In a mixed-methods study, program providers completed an online survey and an individual phone interview regarding their 2019 programming.

RESULTS

Twenty-three programs completed surveys; 20 completed interviews. Program locations included the mid-Atlantic (26%), Northeast (9%), Midwest (30%), Southwest (17%), and Western regions (17%). Although program models varied, programs generally included a health care visit, usually at a safety-net clinic, and nutrition education, typically counseling, advice, or classes. Prescriptions tended to be farmers market vouchers worth a median of $15 a week (interquartile range, $7.81-$20.00). Transportation was a problem for nearly half of the programs.

CONCLUSIONS AND IMPLICATIONS

Current produce prescription program characteristics and operations can serve as a blueprint for new and existing programs. Future research should determine program best practices and the opportunity cost between program standardization and local flexibilities.

A Mixed-Methods Examination of the Impact of the Partnerships to Improve Community Health Produce Prescription Initiative in Northeastern North Carolina

OBJECTIVE

To conduct a mixed-methods examination of the impact of the Partnerships to Improve Community Health produce prescription initiative in northeastern North Carolina.

DESIGN

Quantitative surveys were conducted among participants before and after the distribution of produce prescription vouchers. Univariate statistics were used to describe the participant population, and paired t tests were used to examine change in fruit and vegetable intake. Qualitative, in-depth telephone interviews were conducted among participants, health educators, and food retailers and coded for themes.

SETTING

Eight health promotion programs, 2 food pantries, and 11 food retailers.

PARTICIPANTS

In each health promotion program or food pantry, between 6 and 97 participants were enrolled.

INTERVENTION

Produce prescription vouchers were distributed to participants and redeemed at local food retailers.

MAIN OUTCOME MEASURE S

An increase in local fruit and vegetable purchasing and consumption.

RESULTS

Of the produce prescription participants who completed the baseline survey (n = 93), 86% were female, 64% were African American, and 68% were food insecure. The voucher redemption rate was 18%. The majority of participants indicated that they visit farmers' markets more now than before the produce prescription initiative, that shopping at the farmers' market made it easy to include more fresh produce in their family's diet, and that they tried a new farmers' market because of the produce prescription initiative. All health educators and food retailers who participated felt that the initiative benefited their program or operation and were willing to partner with the program again.

CONCLUSIONS

While redemption rates were lower than anticipated, the produce prescription initiative had positive impacts on participants' local fruit and vegetable purchasing and consumption. Because of COVID-19, the initiative was not implemented until late in the North Carolina produce season. Moving forward, the program will start earlier and work with local food retailers to connect with their communities to increase redemption rates.

Promoting Healthy Food Access and Nutrition in Primary Care: A Systematic Scoping Review of Food Prescription Programs

Objective

To conduct a scoping review to synthesize evidence on food prescription programs.

Data Source

A systematic search of PubMed, CINAHL, Web of Science, Embase, and the Cochrane Library was conducted using key words related to setting, interventions, and outcomes.

Study Inclusion and Exclusion Criteria

Publications were eligible if they reported food prescription administered by a health care practitioner (HCP) with the explicit aim of improving healthy food access and consumption, food security (FS), or health.

Data Extraction

A data charting form was used to extract relevant details on intervention characteristics, study methodology, and key findings.

Data Synthesis

Study and intervention characteristics were summarized. We undertook a thematic analysis to identify and report on themes. A critical appraisal of study quality was conducted using the Mixed Methods Appraisal Tool (MMAT).

Results

A total of 6145 abstracts were screened and 23 manuscripts were included in the review. Food prescriptions may improve fruit and vegetable consumption and reduce food insecurity (FI). Evidence for impacts on diet-related health outcomes is limited and mixed. The overall quality of included studies was weak. Addressing barriers such as stigma, transportation, and poor nutrition literacy may increase utilization of food prescriptions.

Conclusion

Food prescriptions are a promising health care intervention. There is a need for rigorous studies that incorporate larger sample sizes, control groups, and validated assessments of dietary intake, food security, and health.

Food Security and Clinical Outcomes of the 2017 Georgia Fruit and Vegetable Prescription Program

OBJECTIVE

Evaluate improvements in food security and health outcomes associated with participation in a produce prescription program.

DESIGN

Program evaluation with repeated measures over 6 months.

SETTING

Six sites across Georgia.

PARTICIPANTS

Of the 159 enrolled through primary care sites, 122 participants were considered graduates (attended at least 3 of the 6 monthly visits). The majority of program graduates were Black (78.7%), earned <$25,000 annually (76.6%), and were food insecure (74.2%).

INTERVENTION

Six-month program offering group-based nutrition and cooking education along with subsidies for fresh produce worth $1 per family member per day, redeemable weekly.

MAIN OUTCOME MEASURES

Food security, blood pressure, body mass index, waist circumference, and glycated hemoglobin.

ANALYSIS

Linear mixed models estimating association of change in outcomes with program visits 1-6. Fixed effects included participant sex and age, whereas random effects included random intercepts and slopes for the site of program participation and participants.

RESULTS

Participation in a produce prescription program combining subsidies for produce and nutrition education decreased food insecurity (P < 0.001) and diastolic blood pressure significantly (P = 0.019).

CONCLUSIONS AND IMPLICATIONS

These findings highlight the promise of this program and similar programs for improving patient food security and health outcomes among the most vulnerable, underserved communities while aiding in setting realistic expectations and suggestions for program implementation.

Strategies and Challenges: Qualitative Lessons Learned From Georgia Produce Prescription Programs

Produce prescription programs (PPPs) have grown in numbers in the past decade, empowering health care providers to promote health by issuing subsidies for produce to vulnerable patients. However, little research has been conducted on the facilitators that make it easier for PPPs to succeed or the barriers that programs face, which could provide guidance on how to improve future PPP design and implementation. The study sought to identify the facilitators and barriers affecting positive outcomes in Georgia PPPs called Fruit and Vegetable Prescription (FVRx) Programs. A process evaluation with a qualitative comparative case study approach was conducted. Fifteen FVRx providers, ranging from nutrition educators to farmers market managers, were interviewed in a focus group interview or on the phone between 2016 and 2017. Two nutrition education classes and an FVRx best practices meeting were observed, and program documents were collected. Interview transcripts, field notes from observations, and documents were then thematically analyzed. Four overall themes were determined regarding facilitators and barriers experienced by FVRx programs: (1) creating accessible programming may encourage FVRx participation, (2) provider dedication to the program is important, (3) participants' challenging life circumstances can make participation difficult, and (4) the sustainability of the program is a concern. The findings of this study suggest helpful strategies and challenges for providers to consider when developing and implementing PPPs in Georgia and beyond. Research on the long-term program impact is needed, and policy options for sustainable, scaling up of PPPs should be explored.

"I was eating more fruits and veggies than I have in years": a mixed methods evaluation of a fresh food prescription intervention

Background

Food insecurity is associated with poor nutritional health outcomes. Prescribing fresh fruits and vegetables in healthcare settings may be an opportunity to link patients with community supports to promote healthy diets and improve food security. This mixed methods study evaluated the impacts of a fresh food prescription pilot program.

Methods

The study took place at two Community Health Centre locations in Guelph, Ontario, Canada. Sixty food insecure patients with ≥1 cardio-metabolic condition or micronutrient deficiency participated in the intervention. Participants were prescribed 12 weekly vouchers to Community Food Markets. We conducted a one-group pre-post mixed-methods evaluation to assess changes in fruit and vegetable intake, self-reported health, food security, and perceived food environments. Surveys were conducted at baseline and follow-up and semi-structured interviews with participants were conducted following the intervention.

Results

Food security and fruit and vegetable consumption improved following the intervention. Food security scores increased by 1.6 points, on average (p < 0.001). Consumption of fruits and 'other' vegetables (cucumber, celery, cabbage, cauliflower, squashes, and vegetable juice) increased from baseline to follow-up (p < 0.05). No changes in self-reported physical or mental health were observed. Qualitative data suggested that the intervention benefited the availability, accessibility, affordability, acceptability, and accommodation of healthy foods for participating households.

Conclusions

Fresh food prescription programs may be a useful model for healthcare providers to improve patients' food environments, healthy food consumption, and food security.

The food pharmacy: Theory, implementation, and opportunities

The food pharmacy is an emerging program model designed to increase the access to and consumption of healthful foods, particularly fruits and vegetables. Existing research on the efficacy of the food pharmacy model shows that these programs have been effective in improving patient understanding of nutrition and removing barriers to healthy eating, and in turn may have a significant impact on diet-related health outcomes. However, efforts to date aiming to evaluate program effectiveness have been small and lack rigorous research methods. More research is needed to adequately assess the longitudinal effects of food pharmacy programs on healthful food intake and diet-related health outcomes. In this review, we outline the strengths and limitations of previous programs and explore possible options to improve the scalability and sustainability of food pharmacy programs.

An exploration of key barriers to healthcare providers' use of food prescription (FRx) interventions in the rural South

OBJECTIVE

The purpose of this exploratory study was to examine the attitude towards food prescriptions (FRx) interventions among clinicians and identify potential barriers to their use in clinical practice.

DESIGN

The current study employed an exploratory research design using in-depth semi-structured interviews. Research participants were selected from primary care facilities, family practice offices and obesity clinics located in Mississippi and Louisiana.

SETTING

Providers selected for participation in the current study serve predominantly rural, low-income communities in the US South.

PARTICIPANTS

From an original population of fifty healthcare providers that included physicians, registered dieticians and nurse practitioners, from Oxford, Tupelo, Batesville, Jackson, and Charleston, MS and New Orleans, LA. Fifteen healthcare providers agreed to participate, including three physicians, four registered dieticians, three nurses and three nurse practitioners.

RESULTS

The current study found that while healthcare providers expressed a desire to use FRx interventions, there was a universal lack of understanding by healthcare providers of what FRx interventions were, how they were implemented and what outcomes they were likely to influence.

CONCLUSIONS

The current study identified key bottlenecks in the use of FRx interventions at the clinic level and data provided evidence for two key recommendations: (1) development and validation of a screening tool to be used by clinicians for enrolling patients in such interventions and (2) implementation of nutrition education in primary professional training, as well as in continuing education.

A Systematic Scoping Review of How Healthcare Organizations Are Facilitating Access to Fruits and Vegetables in Their Patient Populations

BACKGROUND

There is compelling evidence on the impact of diet as preventative medicine, and with rising health care costs healthcare organizations are attempting to identify interventions to improve patient health outcomes.

OBJECTIVES

The purpose of this systematic scoping review was to characterize existing healthcare organization-based interventions to improve access to fruits and vegetables (F&V) for their patient populations. In addition, we aimed to review the impact of identified interventions on dietary intake and health outcomes.

METHODS

Titles and abstracts were searched in PubMed® (MEDLINE®), Embase®, CINAHL®, and the Cochrane Library® from 1 January 1990 to 31 December 2019. To be selected for inclusion, original studies must have included a healthcare organization and have had a programmatic focus on increasing access to or providing fresh F&V to patients in an outpatient, naturalistic setting. The Effective Public Health Practice Project tool was used to assess study quality in 6 domains (selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts).

RESULTS

A total of 8876 abstracts were screened, yielding 44 manuscripts or abstracts from 27 programs. Six program models were identified: 1) a cash-back rebate program, 2) F&V voucher programs, 3) garden-based programs, 4) subsidized food box programs, 5) home-delivery meal programs, and 6) collaborative food pantry-clinical programs. Only 6 of 27 studies included a control group. The overall quality of the studies was weak due to participant selection bias and incomplete reporting on data collection tools, confounders, and dropouts. Given the heterogeneity of outcomes measured and weak study quality, conclusions regarding dietary and health-related outcomes were limited.

CONCLUSIONS

Healthcare-based initiatives to improve patient access to F&V are novel and have promise. However, future studies will need rigorous study designs and validated data collection tools, particularly related to dietary intake, to better determine the effect of these interventions on health-related outcomes.