Translational Science Benefits
Summary
Food insecurity, or difficulty accessing sufficient and adequate food,1 is common in the United States and especially in Rhode Island where up to 33% of people experience food insecurity.2 Produce prescription programs allow people experiencing food insecurity to receive subsidized fruits and vegetables via referral from a healthcare provider. Such programs have been shown to be an effective “food is medicine”3,4 intervention to improve healthcare outcomes and reduce food insecurity.5-7 Prescription programs have become increasingly common, but there are barriers to their reach and adoption.8
In this two-phase pilot study funded by the Peter G. Peterson Foundation, researchers at Brown University (Multiple Principal Investigators Frank & Tovar) partnered with Integra Community Care Network, an accountable care organization, and Southside Community Land Trust (SCLT), a local nonprofit that collects and packs produce. Integra launched a produce prescription program in 2020 that successfully provided vegetables (via SCLT) to 34 households but faced challenges in reaching as many patients as possible. Through our partnership with Integra and SCLT, we sought to: (1) formally evaluate barriers and facilitators to patient and provider adoption of the produce prescription program through qualitative interviews with patients and primary care staff; (2) work with a community advisory board to develop a set of implementation strategies (i.e., an implementation blueprint9); to address identified barriers; and (3) conduct a pilot study to assess implementation outcomes and preliminary effectiveness outcomes.
Significance
Produce prescription programs have the potential to address diet-related illness and food insecurity through the provision of low or no cost “prescriptions” for vegetables. Such programs directly remove barriers related to cost and access and have the potential to improve public health by reducing disease burden and physical health risks associated with a nutritionally impoverished diet.10 By expanding the reach of produce prescription programs, this study has the potential to reduce the impact of food insecurity in the state of Rhode Island, where rates of food insecurity are especially high. Furthermore, this project has led to our team’s participation in a state-wide initiative to bring together five existing produce prescription programs in the state. The goal of this initiative is to create a shared vision of growth and sustainability for making produce prescriptions available to all Rhode Islanders experiencing food insecurity and diet-related illness.
Approximately one third of people in Rhode Island experience food insecurity due to high food prices.2 Communities of color are disproportionately affected by food insecurity, with approximately half of Black and Latino households in Rhode Island experiencing food insecurity.2 Produce prescription programs have the potential to directly address food insecurity by providing consistent access to fresh vegetables and to advance food equity by providing access to culturally appropriate foods.11 We sought to directly understand the priorities and needs of families receiving produce prescriptions in this study by conducting qualitative interviews (in English and in Spanish) with people who previously participated in the program. Interviews were guided by the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0), which considers factors influencing implementation at multiple ecological levels including individual, organization, and community contexts. We developed implementation strategies to address barriers to participating in produce prescription programs across these ecological levels. This study aims to advance health equity by improving food security and enhancing health outcomes for people based on their lived experiences.
Benefits
Demonstrated benefits are those that have been observed and are verifiable.
Potential benefits are those logically expected with moderate to high confidence.
More patients enrolled in and received vegetables from the produce prescription program after this project compared to prior years. demonstrated.
Community
Improve diet quality and reduce cardiometabolic risk factors (e.g., BMI, blood pressure) potential.
Community
Produce prescription programs provide low or no-cost “prescriptions” for vegetables, thereby directly removing barriers related to cost and access to fresh produce. This improves access to nutritious foods for individuals and families experiencing food insecurity potential.
Community
Improving access to vegetables, especially culturally appropriate and familiar crops, can improve healthcare outcomes. potential.
Community
Decrease costs associated with diet-related illness and cardiometabolic risk factors. potential.
Economic
Participate in a state-wide initiative to increase coordination of and availability of produce prescription programs. demonstrated.
Policy
This research has community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.10
Community
Produce prescription programs are effective at reducing food insecurity, and there is preliminary evidence that they may reduce cardiometabolic risk factors.11 Results from this study will inform a larger study that will test whether the strategies we developed result in more access to produce prescriptions and improved health outcomes. This study directly addressed health care delivery by developing and testing strategies to increase the number of families referred to and receiving produce prescriptions through the program run by Integra. Furthermore, the network of 30 urban farmers who work with Southside Community Land Trust provided local, organic, and culturally appropriate crops that may not be easily found in grocery stores or otherwise accessed by people receiving produce prescriptions. For instance, farmers provided Malabar spinach and sweet potato greens, which are familiar to many people in the African community, as well as ají gustoso (“little sweet peppers”), which may be familiar to the Spanish community. We responded to community feedback about the program by providing produce prescriptions via delivery and including information about vegetable storage and use in English and Spanish with each delivery. Results indicate that more families were served (increased reach/adoption) this year compared to past years and that patient and provider perceptions of the program were generally very positive (acceptability).
Economic
This program directly removed barriers associated with cost and access, potentially resulting in both immediate savings for communities as well as long term savings associated with improved health and wellbeing. In particular, eating fresh produce can improve cardiometabolic risk factors as well as other diet related illnesses.
Policy
The produce prescription program tested in this study is one of five programs that was invited to be a part of a state-wide initiative to increase coordination of and sustainable funding for produce prescription programs in Rhode Island. We will share results from this study with our partners at the Rhode Island Food Policy Council and collaborate on future efforts to further expand the reach of produce prescription programs. This state-wide cohort is working to coordinate produce prescription programs and will lead advocacy efforts to increase funding for produce prescription programs across the state.
Lessons Learned
Our study was grounded in a strong community partnership with Integra (the accountable care organization who funds the produce prescription program), Southside Community Land Trust (the non-profit who provides the vegetables for the program), and the primary care practices who refer to the program. Furthermore, we sought input directly from people who had previously received vegetables through the program. Input from these partners was integral to the success of this project and the expanded reach of the produce prescription program. Identifying mechanisms for sustainable funding and sustained delivery of our selected implementation strategies will be a focus of our next collaboration with our partners. Partnering with policy advocates (i.e., the Rhode Island Food Policy Council) in our ongoing work will also ensure that the impacts of this project continue to grow.
- Barrett CB. Measuring food insecurity. Science. 2010;327(5967):825–8.
- Rhode Island Community Food Bank. 2023 status report on hunger in Rhode Island. 2023.
- Biden-Harris Administration. White House Conference on Hunger, Nutrition, and Health. Washington, DC. 2022.
- Downer S, Berkowitz SA, Harlan TS, Olstad DL, Mozaffarian D. Food is medicine: actions to integrate food and nutrition into healthcare. BMJ. 2020;369:m2482.
- Herman DR, Harrison GG, Jenks E. Choices made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase. J Am Diet Assoc. 2006;106(5):740–4.
- Jones LJ, VanWassenhove-Paetzold J, Thomas K, Bancroft C, Ziatyk EQ, Kim LS, Shirley A, Warren AC, Hamilton L, George CV, Begay MG, Wilmot T, Tsosie M, Ellis E, Selig SM, Gall G, Shin SS. Impact of a Fruit and Vegetable Prescription Program on health outcomes and behaviors in young Navajo children. Curr Dev Nutr. 2020;4(8):nzaa109.
- Trapl ES, Smith S, Joshi K, Osborne A, Benko M, Matos AT, Bolen S. Dietary impact of produce prescriptions for patients with hypertension. Prev Chronic Dis. 2018;15:E138.
- Newman T, Lee JS. Strategies and challenges: qualitative lessons learned from Georgia produce prescription programs. Health Promot Pract. 2022;23(4):699–707.
- Lewis CC, Scott K, Marriott BR. A methodology for generating a tailored implementation blueprint: an exemplar from a youth residential setting. Implement Sci. 2018;13(1):68.
- Institute of Clinical & Translational Sciences at Washington University in St. Louis. Translational Science Benefits Model website. Published February 1, 2019.
- Bhat, S., Coyle, D. H., Trieu, K., Neal, B., Mozaffarian, D., Marklund, M., & Wu, J. H. (2021). Healthy Food Prescription Programs and their Impact on Dietary Behavior and Cardiometabolic Risk Factors: A Systematic Review and Meta-Analysis. Advances in nutrition, 12(5), 1944–1956.