Fruit and Vegetable Prescriptions for Pediatric Patients Living in Flint, Michigan: A Cross-Sectional Study of Food Security and Dietary Patterns at Baseline

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.

Treasure (Hunt for) Your Health! Addressing Pediatric Social Determinants of Health Through Child-Friendly Community Engagement Events

Social determinants of health (SDoH), including factors such as education level, housing, poverty, racism, and food insecurity and their impact on health outcomes have been well documented. The "Wayne Pediatrics Health and Nutrition Expo" held at Detroit's Eastern Market was an activity-based health and nutrition event addressing pediatric SDoH. Partnering with community organizations, the event had 10 stations addressing SDoH: access to a primary-care pediatrician; HIV-care and prevention; childhood literacy; clothing & winter coats; mental health and childhood development; nutrition; staying active; vaccination; and food insecurity. The free, public event featured a child-themed treasure hunt and map, music, giveaways, and live demonstrations, all in a family-friendly park atmosphere. While SDoH are considered "non-medical" factors that contribute to health and may be difficult to completely address for any individual child, our practice addressed several key SDoH at a single-day, hands-on, child-friendly community event based on the local needs of children.

'Nobody Shops at the Neighborhood Store': Leveraging a Community's Pediatric Fresh Produce Prescription Program to Inform Future Participating Store Redemption Locations

Research examining the nature of food shopping often considers proximity to the nearest or overall distance travelled to multiple stores. Such studies make up a portion of new work on so-called 'food deserts' and the issues inherent in the term, including that most people do not shop at their nearest store, and mobility challenges vary vastly from one person to the next. Increasing the knowledge base on shopping characteristics could be useful for behavioral interventions and programs aimed at increasing healthy food shopping. In this study, we examined the shopping characteristics of 627 caregivers whose children were enrolled in a pediatric fresh produce prescription program at one of three large pediatric clinics in Flint, Michigan. We compared these characteristics to the potential of a new food cooperative to improve geographic accessibility to healthy food. In particular, we propose the expansion of the prescription program to this new cooperative for health-related as well as local economic development reasons. Our work bridges topics of interest to researchers and practitioners working in nutrition, food access, and economic development.

Determinants of vegetable intake among urban socio-economically disadvantaged adolescents: a systematic review of quantitative studies

OBJECTIVE

To investigate the determinants of vegetable intake in urban socio-economically disadvantaged adolescents to inform the development of an intervention programme.

DESIGN

A narrative systematic review was carried out by searching five electronic databases from 2013 to 2020. The descriptors used for the search strategy were vegetable intake, adolescents, determinants and correlates. Inclusion criteria were including a sample of socio-economically disadvantaged adolescents aged 12-18 years, evaluation of the association between vegetable intake and determinants of intake, and conducted in urban settings of high-income countries. Thirteen studies met the inclusion criteria. Identified determinants of vegetable intake were reported according to the five levels of the socio-ecological model of health.

SETTING

Studies included in the review were conducted in four countries: USA (n 8), Australia (n 3), Ireland (n 1) and New Zealand (n 1).

PARTICIPANTS

Adolescents aged 12-18 years from socio-economically disadvantaged backgrounds living in urban settings.

RESULTS

Thirty-nine determinants were identified. Nutrition knowledge was the only determinant consistently investigated in several independent samples which was not associated with vegetable intake in socio-economically disadvantaged adolescents. For the remaining potential determinants, it was not possible to examine the consistency of evidence as there were not enough studies investigating the same determinants. Most of the studies followed a cross-sectional design and were carried out in school settings.

CONCLUSIONS

There is a need for further studies on the determinants of vegetable intake in this population preferably with longitudinal designs and beyond the school setting in different countries to guide the development of successful interventions.

Feasibility of a Home-Delivery Produce Prescription Program to Address Food Insecurity and Diet Quality in Adults and Children

Produce prescription programs aim to improve food insecurity (FI) and nutrition but their effectiveness is unclear. We conducted a pilot study to demonstrate the feasibility and explore the potential impact of a family-based, home-delivery produce prescription and nutrition education program. We measured enrollment, satisfaction, participation, and retention as measure of feasibility. Adult participants answered pre-post self-report questionnaires assessing FI, child and adult fruit and vegetable intake, and culinary literacy and self-efficacy. To understand participants' lived experiences, qualitative interviews were conducted at the 6-month time point. Twenty-five families were enrolled. Feasibility measures indicate participants were generally satisfied with the program but there were important barriers to participation. Qualitative data revealed themes around reduced food hardship, healthy eating, budget flexibility, and family bonding. Fruit and vegetable consumption increased in a small subgroup of children, but post-intervention intake remained below recommended levels, particularly for vegetables. FI scores were not significantly different post-intervention, but qualitative findings indicated improved access and reliability of food. This is the first intervention of its kind to be evaluated for feasibility and our results suggest the intervention is well-received and supportive. However, further study, with a larger sample size, is needed to understand factors influencing participation and assess effectiveness.

Effect of a pediatric fruit and vegetable prescription program on child dietary patterns, food security, and weight status: a study protocol

Background

Although nutrients in fruits and vegetables are necessary for proper development and disease prevention, most US children consume fewer servings than recommended. Prescriptions for fruits and vegetables, written by physicians to exchange for fresh produce, address access and affordability challenges while emphasizing the vital role of diet in health promotion and disease prevention. Michigan’s first fruit and vegetable prescription program (FVPP) exclusively for children was introduced in 2016 at one large pediatric clinic in Flint and expanded to a second clinic in 2018. The program provides one $15 prescription for fresh produce to all pediatric patients at every office visit. Prescriptions are redeemable at a year-round farmers’ market or a local mobile market. The current study will assess the impact of this FVPP on diet, food security, and weight status of youth.

Methods

Demographically similar pediatric patient groups with varying levels of exposure to the FVPP at baseline will be compared: high exposure (> 24 months), moderate exposure (12–24 months), and no previous exposure. Data collection will focus on youth ages 8–16 years. A total of 700 caregiver-child dyads (one caregiver and one child per household) will be enrolled in the study, with approximately 200 dyads at clinic 1 (high exposure); 200 dyads at clinic 2 (moderate exposure), and 300 dyads at clinic 3 (no previous exposure). Children with no previous exposure will be introduced to the FVPP, and changes in diet, food security, and weight status will be tracked over two years. Specific aims are to (1) compare baseline diet, food security, and weight status between pediatric patients with varying levels of exposure to the FVPP; (2) measure changes in diet, food security, and weight status before and after never-before-exposed children are introduced to the FVPP; and (3) compare mean 12- and 24-month follow-up measures of diet, food security, and weight status in the initial no exposure group to baseline measures in the high exposure group.

Discussion

Completion of study aims will provide evidence for the effectiveness of pediatric FVPPs and insights regarding the duration and intensity of exposure necessary to influence change.

Trial registration

The study was registered through clinicaltrials.gov [ID: NCT04767282] on February 23, 2021.

Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption

OBJECTIVE

Examine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7-18 years) receiving free/reduced-price school meals.

METHODS

Cross-sectional study. Caregiver-child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants.

RESULTS

Among 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44).

CONCLUSIONS AND IMPLICATIONS

In this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.

Barriers and Facilitators to Implementation of Health System Interventions Aiming to Welcome and Protect Immigrant Patients: a Qualitative Study

BACKGROUND

At the same time that federal policymakers have enforced restrictive immigration policies, healthcare systems across the USA are developing, and have implemented, interventions aimed at addressing immigration-related stressors faced by immigrant communities. Yet, little is known about the contextual determinants that influence their implementation success. Using the Consolidated Framework for Implementation Research (CFIR), this study identifies factors enabling or challenging the implementation of interventions aimed at mitigating immigration-related stressors in the healthcare context.

METHODS

We used a qualitative research design to conduct 38 semi-structured interviews with stakeholders involved in implementation of interventions at 25 healthcare facilities across 5 states with the highest undocumented immigrant populations (California, Texas, New York, Florida, and Illinois). Interviews were conducted from May through August 2018. Constant comparative analysis was used to identify barrier and facilitator themes. Deductive coding was thereafter used to categorize themes according to CFIR domain.

RESULTS

Barriers to implementation included perceptions of legal complexity and challenges to adopting such systemic strategies. Facilitators included a national policy climate that had brought immigrant health to the forefront, allowing for leveraging momentum towards institutional change; communication among healthcare personnel; existing community partnerships with immigrant rights and service organizations; and a shared sense of mission centering health equity. Local variation in immigration-related policies (e.g., local law agencies enforcing federal immigration laws) and heterogeneity of local immigrant communities also impacted implementation. Champions and informal leaders were integral to institutional efforts but not sufficient for sustainability. Perceived urgency to act superseded evaluation considerations, with all interventions in initial phases of implementation. Future iterations and evaluations of these interventions are needed to establish best practices and implementation determinants.

CONCLUSION

This is the first systematic study describing implementation determinants of immigration-related interventions across health systems. Identifying these determinants provides guidance to other healthcare organizations to effectively strategize and ensure implementation success.

Linking the Flint Food Store Survey: Is Objective or Perceived Access to Healthy Foods Associated with Glycemic Control in Patients with Type 2 Diabetes?

Type 2 diabetes mellitus (DM-2) remains a significant public health concern, particularly in low-income neighborhoods where healthy foods may be scarcer. Despite the well-known relationship between diet and diabetes, little evidence exists on the connections among the objectively measured community and consumer food environment, perception of food access, and diabetes management or outcomes. This cross-sectional, ecological study represents the first example of combining a GIS-based, objectively measured food store audit considering quality, variety, and price of foods in stores with a clinical survey of patients with DM-2 (n = 126). In this way, we offer evidence on the relationship between healthy food access-measured more robustly than proximity to or density of certain store types-and diabetes management knowledge, medication adherence, and glycemic control. Better glycemic control was not correlated with better overall food store score, meaning that people in neighborhoods with better access to healthy foods are not necessarily more likely to manage their diabetes. While perceived healthy food access was not correlated with glycemic control, it was strongly correlated with objective healthy food access at shorter distances from home. These results have great importance both for clinical understanding of the persistence of poor diabetes management outcomes and for the understanding of the influence of the food environment on health behaviors.

Influence of a Pediatric Fruit and Vegetable Prescription Program on Child Dietary Patterns and Food Security

Limited access to fresh foods is a barrier to adequate consumption of fruits and vegetables among youth, particularly in low-income communities. The current study sought to examine preliminary effectiveness of a fruit and vegetable prescription program (FVPP), which provided one USD 15 prescription to pediatric patients during office visits. The central hypothesis was that exposure to this FVPP is associated with improvements in dietary patterns and food security. This non-controlled longitudinal intervention trial included a sample of caregiver–child dyads at one urban pediatric clinic who were exposed to the FVPP for 1 year. Patients received one USD 15 prescription for fresh produce during appointments. A consecutive sample of caregivers whose children were 8–18 years of age were invited to participate in the study. Dyads separately completed surveys that evaluated food security and dietary behaviors prior to receipt of their first prescription and again at 12 months. A total of 122 dyads completed surveys at baseline and 12-month follow-up. Approximately half of youth were female (52%), and most were African American (63%). Mean caregiver-reported household food security improved from baseline to 12 months (p < 0.001), as did mean child-reported food security (p = 0.01). Additionally, child-reported intake of vegetables (p = 0.001), whole grains (p = 0.001), fiber (p = 0.008), and dairy (p < 0.001) improved after 12 months of exposure to the FVPP. This study provides evidence that pediatric FVPPs may positively influence food security and the dietary patterns of children.

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.

Distributing and Sourcing Local Produce in Latino-focused Food Stores: A Qualitative Study with Stores and Small Farmers in San Diego County

A strategy to address challenges in sourcing and maintaining produce in tiendas is to build a new localized food economy. Key informant interviews were conducted with tienda owners and managers and small produce farmers to understand produce distribution and sourcing behaviors, and to identify the potential to connect tiendas with small produce farmers. Interviews were analyzed using an inductive coding approach and were summarized into three themes: people, place, and product. Results provide context for understanding factors that affect access to local produce in Latino communities. Future research should be conducted with produce distributors, and policy-level strategies should be considered.

Participation in a Fruit and Vegetable Prescription Program for Pediatric Patients is Positively Associated with Farmers' Market Shopping

Objectives: The primary objective was to investigate the association between participation in a farmers’ market fruit and vegetable prescription program (FVPP) for pediatric patients and farmers’ market shopping. Methods: This survey-based cross-sectional study assessed data from a convenience sample of 157 caregivers at an urban pediatric clinic co-located with a farmers’ market. Prescription redemption was restricted to the farmers’ market. Data were examined using chi-square analysis and independent samples t-tests. Results: Approximately 65% of respondents participated in the FVPP. Those who received one or more prescriptions were significantly more likely to shop at the farmers’ market during the previous month when compared to those who never received a prescription (p = 0.005). Conclusions: This is the first study to demonstrate that participation in a FVPP for pediatric patients is positively associated with farmers’ market shopping.

Assessment of Perspectives on Health Care System Efforts to Mitigate Perceived Risks Among Immigrants in the United States: A Qualitative Study

IMPORTANCE

Increases in the enforcement of immigration policies, deportations, and rhetoric critical of immigration during and after the 2016 US presidential election have been associated with a decrease in health-seeking behaviors and an increase in adverse health outcomes among immigrants. Efforts to address the health care needs of immigrants after the 2016 presidential election have centered on individual-level patient-practitioner strategies or federal- and state-level policy changes. However, these approaches have not captured the role of health care systems and the range of health care facilities encompassed within them.

OBJECTIVE

To characterize policies and actions implemented by health care facilities to address immigration status-related stressors.

DESIGN, SETTING, AND PARTICIPANTS

This exploratory qualitative study involved semistructured interviews in a purposive sample of health care facilities across 5 states (California, Texas, New York, Florida, and Illinois) with the largest populations of individuals with undocumented immigration status. Data from media sources and informational interviews with local immigration advocacy leaders were used to identify health care facilities that had implemented welcoming policies and strategies. Stakeholders, including administrators, frontline clinicians involved in policy implementation, and senior executive leaders, were interviewed. Interviews were conducted between May 1 and August 9, 2018, and were recorded, transcribed, and coded using constant comparative analysis. Data analysis was performed from June 29, 2018, to February 5, 2019.

MAIN OUTCOMES AND MEASURES

Stakeholder perspectives on the range, scope and content of policies and actions implemented to address immigration-related stressors at health care facilities.

RESULTS

A total of 38 in-depth interviews were conducted spanning 25 health care facilities in 5 states; these facilities included 13 federally qualified health centers, 7 academic or private hospitals, and 5 public institutions. Interviewees described policies and actions that mitigated one or more of the following perceived risks: (1) risk of exposure to immigration enforcement personnel at or near facilities, (2) risk of immigration status-related information disclosure, (3) risk associated with patient-level stressors, (4) risk associated with practitioner-level stressors, and (5) coordination of risk mitigation. Most personnel at health care facilities emphasized that their policies and actions fit within a larger mission and history of addressing the social needs of diverse patients and mitigating risks for patients.

CONCLUSIONS AND RELEVANCE

Health care facilities can implement both active and reactive measures to address perceived immigration-associated risks among patients and practitioners. Population health and immigration policies are at the forefront of current policy debates. An understanding of the ways in which health care facilities can serve to mitigate perceived risks among their patients and employees can be one step toward optimizing health care for immigrants.

Effects of In-Person Assistance vs Personalized Written Resources About Social Services on Household Social Risks and Child and Caregiver Health: A Randomized Clinical Trial

IMPORTANCE

Social and economic contexts shape children's short- and long-term health. Efforts to address contextual risk factors are increasingly incorporated into pediatric health care.

OBJECTIVE

To compare the effectiveness of 2 social risk-related interventions.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included English- and/or Spanish-speaking caregiver-child dyads recruited from a pediatric urgent care clinic nested in a large, urban, safety-net hospital. Study recruitment, enrollment, and follow-up were conducted from July 18, 2016, to March 8, 2019. Data analysis was conducted from January 1, 2019, to January 20, 2020.

INTERVENTIONS

Following standardized social risk assessment, caregivers were randomly assigned to receive either written information regarding relevant government and community social services resources or comparable written information plus in-person assistance and follow-up focused on service access.

MAIN OUTCOMES AND MEASURES

Caregiver-reported number of social risk factors and child health 6 months after enrollment.

RESULTS

Among 611 caregiver-child dyads enrolled in the study, 302 dyads were randomized to the written resources group and 309 dyads were randomized to the written resources plus in-person assistance group. The mean (SD) age of children was 6.1 (5.0) years; 483 children (79.1%) were Hispanic; and 315 children (51.6%) were girls. There were no significant differences between groups in the effects of the interventions. In post hoc secondary analyses, the number of reported social risks decreased from baseline to 6-month follow-up in both groups: caregivers who received written resources alone reported a mean (SE) of 1.28 (0.19) fewer risks at follow-up, while those receiving written resources plus in-person assistance reported 1.74 (0.21) fewer risks at follow-up (both P < .001). In both groups, there were small but statistically significant improvements from baseline to follow-up in child health (mean [SE] change: written resources, 0.37 [0.07]; written resources plus in-person assistance, 0.24 [0.07]; both P < .001).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial compared 2 approaches to addressing social risks in a pediatric urgent care setting and found no statistically significant differences in the social risk and child and caregiver health effects of providing written resources at the point of care with vs without in-person longitudinal navigation services. Caregivers in both groups reported fewer social risks and improved child and caregiver health 6 months after the intervention. These findings deepen understanding of effective doses of social risk-related interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02746393.

Child Consumption of Whole Fruit and Fruit Juice Following Six Months of Exposure to a Pediatric Fruit and Vegetable Prescription Program

Public health recommendations suggest limiting child consumption of fruit juice in favor of whole fruit due to juice’s high sugar content, lack of fruit fiber, and potential for excess intake. However, replacing juice with whole fruit may be particularly challenging for low-income and minority children, who report the highest intake of 100% juice. To address access and affordability challenges among low-income children, researchers partnered with pediatricians in an urban food desert community, to introduce a fruit and vegetable prescription program (FVPP) that provided a $15 prescription for fresh produce to every child during each office visit. Participating vendors included a farmers’ market and local mobile market. This study assessed changes in daily consumption of total fruit and whole fruit among 108 pediatric patients following six months of exposure to the FVPP. Child-reported mean daily intake of whole fruit increased significantly from the baseline to the 6-month follow-up (p = 0.03): 44% of children reported an increased intake of at least ¼ cup per day, and 30% reported an increased intake of at least ½ cup per day. Changes in total fruit intake (including fruit juice) were not significant. Results suggest a pediatric FVPP may have meaningful impacts on children’s dietary behaviors, particularly with regard to the intake of whole fruits.

Caregiver Experiences With an Innovative Farmers' Market Incentive Program for Children in Flint, Michigan

An innovative farmers’ market incentive program designed specifically for children was implemented to address persistent challenges with accessing fresh, nutrient-rich foods in a food desert community. The current study sought to qualitatively examine caregiver perceptions of the incentive program. Following distribution of farmers’ market incentives to all children (ages 0 to 15 years) at 43 Flint-area early childcare facilities and elementary schools, researchers conducted semistructured interviews with 37 caregivers (mean age = 39.59 ± 11.73 years). The majority were female (87%) and African American (53%). Through these interviews, researchers explored family experiences with the farmers’ market incentive program, as well as changes in environmental factors that may have resulted from program participation. Interviews were audio recorded and transcribed verbatim for textual analysis. Thematic analysis was used to identify patterns across transcripts and formulate emerging themes. Four recurrent themes emerged during interviews: (1) fruit and vegetable access, (2) child influence, (3) autonomous grocery shopping, and (4) program expansion. Interview participants indicated that the farmers’ market incentive program was an effective tool to both encourage families to visit the farmers’ market and purchase fresh foods there. Program design, particularly distribution to children, was credited with introducing families to the local farmers’ market. The current study suggests that a farmers’ market incentive program targeting children who reside in a food desert community may have meaningful impacts on access to fresh, nutrient-rich foods.