Introduction
Nutrients in fruits and vegetables are important for appropriate growth and development(Reference Albani, Butler and Traill1–Reference Cohen, Gorski and Gruber8) as well as prevention of diet-related chronic health conditions.(Reference Liu9–Reference Ness, Maynard and Frankel12) Unfortunately, most children and adolescents fall short of meeting dietary recommendations for fruits and vegetables.(Reference Kim, Moore and Galuska13–Reference Lorson, Melgar-Quinonez and Taylor16) Because childhood represents a crucial period of growth when individuals establish enduring dietary habits,(Reference Craigie, Lake and Kelly17–Reference Appannah, Pot and Oddy19) it is imperative that youth have easy access to fresh, nutrient-dense foods, such as fruits and vegetables.
Fruit and vegetable prescription programmes (FVPPs) are one strategy to increase access to fruits and vegetables for young patients.(Reference Saxe-Custack, Kerver and Mphwanthe20–Reference Ridberg, Bell and Merritt24) These programmes vary widely in scope and procedures; however, fruit and vegetable prescriptions are often written by primary care providers, distributed to patients, and exchanged for fresh produce at retailers, such as farmers’ markets, mobile markets, and grocery or food stores.
In addition to supporting food equity, paediatric FVPPs hold promise as both a primary and secondary prevention strategy.(Reference Virudachalam, Kim and Seligman25) Preliminary research has shown that participation in paediatric FVPPs is associated with improvements in food security,(Reference Saxe-Custack, LaChance and Jess21,Reference Ridberg, Bell and Merritt24) food shopping,(Reference Saxe-Custack, Sadler and LaChance26) and youth dietary intake.(Reference Saxe-Custack, LaChance and Jess21,Reference Saxe-Custack, LaChance and Hanna-Attisha27–Reference Buscail, Margat and Petit30) Thus far, however, there is a shortage of literature that explores environmental barriers to engagement in these programmes.(Reference Esquivel, Higa and Guidry23) Because the effectiveness of paediatric FVPPs is largely dependent upon programme engagement among caregivers and their families, an investigation of barriers to participation is crucial. Moreover, as research continues to explore the short- and long-term implications of various models of paediatric FVPPs, qualitative research must simultaneously consider the limitations of differing programme designs.
In February 2016, Hurley Children’s Center, a large paediatric clinic in Flint, Michigan, partnered with a local farmers’ market to create Michigan’s first fruit and vegetable prescription programme solely for children.(Reference Saxe-Custack, Sadler and LaChance26,Reference Saxe-Custack, Lofton and Hanna-Attisha31) The programme provided one $15 prescription for fresh produce to every child, regardless of health status or income, at every office visit. Participants exchanged prescriptions for fresh produce at the Flint Farmers’ Market or at Flint Fresh, a local mobile market and food hub. In August 2018, this identical programme was introduced at a second paediatric clinic in Flint as part of a study to examine replicability and preliminary effectiveness.(Reference Saxe-Custack, LaChance and Jess21,Reference Saxe-Custack, LaChance and Hanna-Attisha27) The current study sought to qualitatively explore caregiver understanding of this paediatric FVPP, barriers to programme engagement, and recommendations for improvement.
Experimental methods
Study setting and population
Flint, Michigan has approximately 100,000 residents and is home to General Motors. When the American automobile industry declined, Flint fell into an extreme recession.(Reference DeWitt32) In addition to a child poverty rate that is approximately 50%,(33) youth in Flint continue to struggle in the aftermath of a city-wide lead-contaminated water public health crisis.(Reference Hanna-Attisha, LaChance and Sadler34) Additionally, Flint lacks nutrition resources and healthy food options. Poor quality fresh foods in local food stores limit access to nutrient-rich items, such as fruits and vegetables,(Reference Saxe-Custack, Lofton and Hanna-Attisha31,Reference Shaver, Sadler and Hill35,Reference Mayfield, Carolan and Weatherspoon36) and grocery store options in the city are scarce.(Reference Sadler37)
Paediatric fruit and vegetable prescription programme (FVPP)
Hurley Children’s Center, a residency-training paediatric clinic co-located within a farmers’ market, introduced the first paediatric fresh fruit and vegetable prescription programme (FVPP) in Michigan in February 2016. This FVPP was established to actively address enduring challenges with accessing and purchasing fresh produce among youth and families living in Flint. The FVPP was thoughtfully designed to easily integrate into the busy paediatric office while highlighting the importance of daily fruit and vegetable consumption. Prescriptions were added to the clinic’s electronic medical record (EMR) system and retained in patient records. Paediatricians ordered produce prescriptions using the EMR system and distributed the printed prescriptions to all paediatric patients at every office visit. The EMR generated monthly prescription distribution reports, which were used to track clinic-wide distribution rates.
The FVPP originally introduced at Hurley Children’s Center(Reference Saxe-Custack, Sadler and LaChance26,Reference Saxe-Custack, Lofton and Hanna-Attisha31) was expanded to one private-practice paediatric clinic in Flint in August 2018. This second clinic, Akpinar Children’s Clinic, provides care to 3000 patients, most of whom live in Flint and receive public health insurance. Identical to the original programme, the paediatrician ordered $15 fruit and vegetable prescriptions using the EMR system and gave the prescriptions to all patients during office visits. FVPP vendors included Flint Farmers’ Market, a year-round market located in downtown Flint, open Tuesday, Thursday, and Saturday from 9 AM until 5 PM, and Flint Fresh, a mobile market and food hub, that offered free delivery of participant-selected fresh produce boxes. Prescriptions were treated as vouchers that could only be exchanged for fresh fruits and vegetables and were valid for 90 days. Participants could not divide their prescription between multiple farmers’ market vendors, and any remaining balance from a transaction totalling less than $15 was lost.
From August 2018 through March 2019, 365 caregiver–child dyads at Akpinar Children’s Clinic provided written consent and assent to join a study assessing the feasibility of the FVPP,(Reference Saxe-Custack, LaChance and Jess21,Reference Saxe-Custack, LaChance and Hanna-Attisha27) including follow-up interviews to assess programme experiences.
Approach and theoretical framework
The study design and approach followed the theoretical framework of Bandura’s Social Cognitive Theory (SCT). SCT explains behaviour through a 3-stage model connecting personal factors, environmental factors, and behaviour.(Reference Bandura38) Since children’s nutrition choices are typically guided by their caregivers,(Reference Draxten, Fulkerson and Friend39,Reference Haß and Hartmann40) a qualitative investigation of environmental factors that prevented caregivers from fully engaging in the programme with their children was of particular importance.
Participants and data collection
Researchers collected data via semi-structured telephone interviews between December 2022 and March 2023. Distribution data (EMR reports) and redemption data (redeemed paper prescriptions) were used to identify children who enrolled in the original study with their caregiver but failed to redeem fresh produce prescriptions during the approximate four-year study period. To assess barriers to engagement in the FVPP as well as caregiver experiences with the programme, an open-ended interview format was created.
Caregivers were eligible to participate in interviews if: (1) they enrolled in the original study and completed baseline surveys; (2) their enrolled child had received at least one fruit and vegetable prescription; (3) their enrolled child had not redeemed any $15 fruit and vegetable prescriptions during the study period; and (4) their enrolled child was an active patient at Akpinar Children’s Clinic. A total of 98 caregivers met eligibility requirements. Researchers attempted to contact all 98 caregivers but were challenged with non-working or disconnected telephones. After 32 interviews were completed, researchers concluded that no new concepts were arising and that data saturation had been reached. Participants received one $50 electronic gift card after completing the interviews.
The open-ended interview format was used to detect caregiver understanding of the FVPP, barriers to programme engagement, and recommendations for improvement. One-on-one interviews were led by three research team members trained in qualitative research methods. Questions such as In your own words, can you explain the fruit and vegetable prescription program and how it works invited conversation regarding caregiver understanding of the programme and redemption procedures, while more involved questions such as What prevented you from redeeming all of your prescriptions and Do you have specific thoughts or ideas to change the program to address the barriers you have experienced redeeming your prescriptions probed about specific challenges related to programme engagement. Researchers gathered additional information using an interview guide informed by previous literature,(Reference Saxe-Custack, Lofton and Hanna-Attisha31,Reference Wetherill and Gray41–Reference Olsho, Payne and Walker44) research questions, and experiences with the subject matter and population.
Data analysis
All caregiver interviews were audio recorded and transcribed verbatim for textual data analysis. Researchers examined data by following a coding process informed by thematic analysis. During initial coding, four researchers individually analysed transcripts and identified notable patterns for thematic purposes. Researchers then met to collapse similar themes and determine final emerging themes. Lastly, three researchers selected illustrative direct quotes to represent the final themes and sub-themes.
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Michigan State University Institutional Review Board – Study 00000666. Written informed consent was obtained from all subjects.
Results
A total of 32 interviews with caregivers were completed. Interview participants (mean age, 40.9 ± 9.4 years) were primarily female (94%), African American (66%), and residents of Flint (72%) (Table 1). These demographics are representative of the full sample of 365 caregivers who enrolled in the larger study (mean age 39.7 ± 9.9 years), most of whom were female (91%), African American (66%), and residents of Flint (72%).
Characteristics of caregivers who completed interviews
Important to research findings was the general feedback from most caregivers that their household had redeemed at least one prescription during the study period. Although study records accurately tracked and recorded redemption rates for children enrolled in the study, records failed to capture prescription redemption for siblings living in the same household but not enrolled in the study. Only eight of the 32 caregivers interviewed (25%) acknowledged that no child in their household had ever redeemed a produce prescription. We present the following recurrent themes and associated findings, each centred around caregiver experiences with the FVPP: (1) nutrition security; (2) prescription distribution; (3) prescription redemption; (4) educational supports; (5) programme modifications. These themes can be found in Table 2, corresponding with the associated sub-themes.
Illustrative quotes collected from caregivers of children enrolled in a produce prescription programme
Nutrition security
Nutrition security is defined as ‘consistent access, availability, and affordability of foods and beverages that promote well-being, prevent disease, and, if needed, treat disease, particularly among racial/ethnic minority populations, lower income populations, and rural and remote populations’.(Reference Mozaffarian, Fleischhacker and Andrés45) Most caregivers indicated that they had redeemed at least one produce prescription with a child in their household during the study period. These caregivers perceived the FVPP to have meaningful impacts on nutrition security.
A majority of caregivers expressed gratitude for the FVPP as a financial support for their families (Table 2, sub-theme 1.1). Many noted growing concerns regarding the cost of healthy foods, particularly fresh fruits and vegetables, and appreciated the FVPP for alleviating that burden. Some further noted the importance of paediatric office visits, accompanied by produce prescriptions, in directly combating the growing costs of fresh foods.
Sometimes it can be really expensive to get healthy fruits and vegetables. And it’s $15 worth of fruits and vegetables that I don’t have to pay out of pocket… It helps the pockets of low-income families. (Participant 180, African American Female, Age 43)
Since COVID, vegetables are going up [in price]. I don’t get food stamps, so I took the kids to their appointment today. At least I know I’ll get some kind of help for vegetables, fruits and vegetables, by coming in [to the doctor]. (Participant 285, African American Female, Age 42)
Many caregivers recognised the value of the prescription programme in supporting the nutrition and health of their children (Table 2, sub-theme 1.2). Some noted their appreciation for paediatricians who offered the programme, rather than medicine or pills, to actively encourage disease prevention and healthy eating among young patients. Many felt the programme served as an incentive for families to bring their children to the paediatrician.
I think it’s really great that the doctors care enough about our health to want to give us free fruits and vegetables and teach us about nutritional meals… I think that’s definitely the best part, to go to the doctor and walk out with a prescription that’s not a pill. It’s like they are actually wanting you to eat healthy. (Participant 129, Caucasian Female, Age 36)
Many caregivers talked about child engagement in the FVPP, particularly with regard to produce selection at the farmers’ market (Table 2, sub-theme 1.3). Some further described how they planned trips to the farmers’ market to use their prescriptions as an opportunity to educate and bond with their children.
The kids thoroughly enjoyed, and I do mean thoroughly enjoyed, going to the Flint Farmers’ Market giving the vendors their [prescriptions], and picking out their own vegetables. (Participant 312, Caucasian Male, Age 39)
Prescription distribution
Caregivers were asked to explain the FVPP in their own words. Although the majority of caregivers had a general understanding of the programme, key components were consistently unclear among interview participants. Most confusion occurred at the point of distribution (i.e. receipt of produce prescriptions at the paediatric clinic).
In contrast with programme distribution procedures that specified every child should receive one $15 prescription at each office visit, most caregivers indicated that prescriptions were not given during every office visit (Table 2, sub-theme 2.1). Some believed the prescriptions were reserved only for annual well-visits, while others simply explained that prescription distribution was inconsistent across office visits.
If I do a walk-in visit, I don’t get nothing for that. It’s only a scheduled appointment that I ever got [prescriptions]. (Participant 005, African American Female, Age 34)
I received it usually when we do their yearly check-ups. Any other time I was there, it would be an emergency call or something like that. I would receive them [only] when we do the check-up yearly. (Participant 082, African American Female, Age 42)
Nearly every caregiver said that an introduction to the FVPP was provided at the paediatric office when their child received their first prescription. In spite of this programme introduction, many shared that their programme understanding was inadequate (Table 2, sub-theme 2.2). Some confused the FVPP with other food assistance and nutrition incentive programmes. Several admitted that their poor understanding of the FVPP influenced their decision not to redeem prescriptions.
I was trying to take everything in on how to do it. Honestly, I didn’t fully understand how to [use prescriptions]. (Participant 036, Hispanic Female, Age 44)
I didn’t redeem them because of the fact that I didn’t understand that they were for fruits and vegetables. The fresh things at the market. (Participant 085, African American Female, Age 53)
When describing the prescription programme in their own words, most caregivers talked only about the local farmers’ market as the redemption site for prescriptions. A majority of caregivers were entirely unaware of the free produce delivery option through Flint Fresh (Table 2, sub-theme 2.3). Some, who were aware that Flint Fresh was a vendor for the FVPP, lacked general knowledge of this option, such as delivery procedures, radius, or associated costs.
I didn’t even know they had delivery. (Participant 166, African American Female, Age 50)
I was afraid with the delivery service that I was going to be charged. And money is tight, it’s still tight, but I think the delivery service is a really good idea. (Participant 267, Caucasian Female, Age 56)
Prescription redemption
When asked to explain specific barriers to engagement in the FVPP, most caregivers talked extensively about prescription redemption. Some were challenged when navigating redemption sites, both in-person at the farmers’ market and online through Flint Fresh. Caregivers also discussed conflicts related to work hours and farmers’ market hours, challenges with transportation, and management of paper prescriptions. Each of these, alone or in combination, acted as barriers to engagement in the FVPP.
When arriving at the farmers’ market or placing an order on the Flint Fresh website, many caregivers shared their frustration with vendor site navigation (Table 2, sub-theme 3.1). Some were unsure which farmers’ market vendors accepted prescriptions; while others were unclear regarding specifics of redemption, such as exceeding prescription value or splitting the prescription value between vendors. Some caregivers, who attempted to redeem prescriptions through the Flint Fresh website, described technical challenges.
When I got to the farmers’ market and walked in, I didn’t know where to go. So, that’s where I got lost. (Participant 290, African American Female, Age 33)
When I went on the website to try to order [a produce box], for some odd reason it wouldn’t let me continue. I picked all my stuff, but it wouldn’t let me submit it. (Participant 176, African American Female, Age 43)
Although every caregiver expressed genuine appreciation for the prescription programme, many shared continual difficulties related to lost or forgotten paper prescriptions (Table 2, sub-theme 3.2). Some further indicated that when found, prescriptions were very often expired (beyond the 90-day expiration date). A majority of caregivers indicated that the format of prescriptions, small pieces of prescription paper, made tracking and management of the incentive difficult.
I lose them often because it’s such a small piece of paper. I just misplace them. When I do find them again, they are expired. So, that’s a big issue. (Participant 090, Caucasian Female, Age 35)
Many caregivers discussed the exceptional quality of produce and generosity of farmers’ market vendors. However, some commented on limitations of the farmers’ market as the primary produce prescription programme redemption site (Table 2, sub-theme 3.3). Most indicated that the limited hours of operation of the farmers’ market (Tuesday, Thursday, and Saturday from 9:00 AM to 5:00 PM) conflicted with work or family schedules. Some further shared that distance to the farmers’ market or anticipated crowds discouraged prescription redemption there.
It is kind of hard, especially working nine to five… Really the only day I have available, if I’m available that day, is a Saturday. (Participant 180, African American Female, Age 43)
Flint Farmers’ Market is located in downtown Flint. It is easy to access through public transportation, specifically through bus routes. Still, many caregivers discussed challenges related to reliable transportation to the farmers’ market (Table 2, sub-theme 3.4). Some shared problems specifically related to functioning cars, while others felt unsafe accessing public transportation.
I think over the years I’ve probably redeemed them [prescriptions] two or three times only because of lack of transportation. (Participant 166, African American Female, Age 50)
There was one point in time when there was a transportation issue. Even though I did have access to the bus, it wasn’t a safe area to get on the bus. Even though I had access to the bus line, where the bus line was, it wasn’t safe to get on. (Participant 302, Native American/American Indian Female, Age 33)
Educational supports
When asked to describe the type of education that caregivers felt would benefit their families, many indicated that they would like cooking classes or recipes to be offered alongside prescriptions. Some further suggested that educational programmes or sessions should be offered in a virtual format.
Most caregivers requested that culinary programmes be offered with the FVPP (Table 2, sub-theme 4.1). Some caregivers shared struggles encouraging their children to eat more fruits and vegetables and desired a class that would address this challenge. Others believed a youth-focused cooking class would be beneficial.
I have a 15-year-old daughter, and she absolutely would love some [culinary] education if it was presented to her. “Hey, go to the farmers’ market, go buy these things and then you can use them to cook XYZ”. (Participant 312, Caucasian Male, Age 39)
Nearly all caregivers requested that recipes accompany produce prescriptions (Table 2, sub-theme 4.2). Some felt recipes should be distributed with prescriptions; while others suggested fruit and vegetable recipes be provided through a website, regular emails, or farmers’ market kiosk.
Recipes would be awesome… Email or at the doctor. Just have the attendant print [recipes] off. Just hand recipes to you while you are at the doctor’s office. Just like [pediatrician] does with the prescription. (Participant 015, African American Female, Age 43)
A website or recipes you could download. For instance, when you get the prescription, maybe there would be a website for quick meals or quick recipes. Or when we go to the farmers’ market, they give out free recipes or something. (Participant 085, African American Female, Age 53)
Many caregivers suggested that if programme education, including nutrition or culinary instruction, were to be offered with the prescription programme, sessions should be presented in a virtual format (Table 2, sub-theme 4.3). Some noted busy schedules and competing priorities, while others pointed to struggles with transportation. Most felt that offering education virtually would address these barriers.
It’s kind of inconvenient sitting in a class when you’ve got so much to do. I believe something on a QR code or app. So, [participants] can just go on and look it up and maybe even a video to help people and show them what to do. (Participant 033, African American Female, Age 30)
A class or something through Zoom. So that even if a person doesn’t have transportation, most people have cell phones, even the free government phones. So, they would be able to go to a Zoom meeting for the purpose of learning how this program works and things about nutrition. (Participant 190, African American Female, Age 53)
Programme modifications
Throughout the interviews, caregivers were candid regarding modifications that should be made to the current programme to improve engagement. Most interview participants had redeemed at least one produce prescription, and many felt changes could be made to improve the programme experience for families.
The majority of caregivers felt strongly that the paper prescription format needed to be changed (Table 2, sub-theme 5.1). Caregivers offered thoughtful solutions to address the challenges with paper prescriptions. Most clearly indicated a desire for prescriptions to be available through a card or an application (i.e. app) for the entire household. Some further suggested that prescription cards or apps should automatically reload for members of the household following clinic appointments.
An app that’s under an umbrella of all my kids versus individually and me having one for each kid at random times… Just having multiple kids and sending random papers [prescriptions] attached to check-out stuff. I think an app, where I know it’s going to be there, already loaded and ready to go. I think that would be more helpful. (Participant 005, African American Female, Age 34)
A card instead of paper. Because paper is something that can really easily get misplaced. But a card, you can put it inside of your wallet and you’ll be able to see it and say, “Oh yeah, let me go use this.” Even a reusable card that once you go in [to the pediatrician’s office], they just refill it for you. (Participant 015, African American Female, Age 43)
Although most caregivers expressed fondness for the farmers’ market, many felt the programme should expand to include more redemption sites (Table 2, sub-theme 5.2). Specifically, caregivers felt that expansion to full-service grocery stores would increase programme engagement due to their broad selection of food items that would allow caregivers to redeem prescriptions while grocery shopping. Some also mentioned that grocery stores were closer to their homes and more convenient to shop at than the farmers’ market.
[Prescriptions] are only good at the farmers’ market, and I don’t always have the time to go to the farmers’ market. I do a lot of my shopping at [grocery stores], and I can go straight there. I’m not big on going to multiple stores… I like to just go to where I am going and go back home. I have a lot of children, so I don’t really have a lot of time to stop at the farmers’ market as well as other grocery stores. (Participant 033, African American Female, Age 30)
Produce prescriptions expired 90 days from the date of distribution. Many caregivers expressed frustration with these expiration dates (Table 2, sub-theme 5.3). Some asked that the expiration dates be removed from the prescriptions entirely. Others requested that reminder texts or emails be sent to caregivers when prescriptions were nearing their expiration date.
Just a small text message or an email… “Don’t forget to use your coupon by this date.” Like when the doctor reminds you that you have a doctor’s appointment. Because sometimes, as parents, we get overwhelmed and sometimes forget. So, a reminder would definitely help. (Participant 015, African American Female, Age 43)
I don’t know why they have an expiration date. I did go one time, and I was excited to know that I had one of those prescriptions. But it was expired. So, maybe if they didn’t have the expiration dates. (Participant 036, Hispanic Female, Age 44)
Discussion
The current study is among the first to explore and describe caregiver-reported barriers to engagement in a paediatric FVPP. Most caregivers reported that they had redeemed at least one produce prescription with a child in their household and maintained deep gratitude for the programme that served as both a financial and nutritional support for their children. However, many were also forthcoming about the need for programme improvements to increase overall engagement. Central to our findings was a lack of awareness regarding specific features of the programme, such as prescription distribution schedules, vendor details, and redemption rules. Many caregivers further indicated that this lack of clarity influenced their decision not to redeem prescriptions. Additional environmental barriers to redemption included transportation challenges, management of small pieces of prescription paper, and limited farmers’ market selection and hours. Caregivers offered practical suggestions, such as digital prescriptions and partnerships with full-service grocery stores, to address many of the challenges identified during interviews.
Similar to previous qualitative work, caregivers expressed a genuine appreciation for the FVPP, recognising that healthcare providers offered this programme out of concern for the health and well-being of their young patients.(Reference Saxe-Custack, Lofton and Hanna-Attisha31) Some even indicated that the programme served as a motivation for attending regular office visits or as a deterrent from utilising urgent or emergency care services. Although research examining health care utilisation among participants in a paediatric FVPP is unavailable, recent findings suggest that food prescription programmes may reduce emergency department utilisation among adults.(Reference Mayfield, Robinson-Taylor and Rifkin46) Given the importance of regular paediatric visits for immunizations and preventative care, research focused on the influence of paediatric FVPP on health care utilisation is needed. Additionally, feedback from caregivers also signalled a recognition of the impact of the FVPP on nutrition security. Many talked extensively about the growing cost of fresh, healthy foods, with some suggesting that it was more cost-effective to purchase convenience or packaged foods. The paediatric FVPP was viewed as a means for caregivers to provide fresh fruits and vegetables to their households, even as the cost of these items was increasing. This finding is consistent with previous research that indicates paediatric FVPPs have a positive influence on nutrition and food security among youth and their families.(Reference Saxe-Custack, LaChance and Jess21,Reference Ridberg, Bell and Merritt24,Reference Saxe-Custack, Lofton and Hanna-Attisha31)
Similar to research with adults,(Reference Garner, Coombs and Savoie-Roskos47) many caregivers shared a lack of understanding of the paediatric FVPP at the point of distribution (receipt of prescriptions). This finding illustrates the need for a consistent programme education plan and supporting materials at partnering clinics. Previous research has suggested that, in order for FVPPs to run effectively, a paid staff member should be responsible for coordinating the programme at clinics and managing education, referrals, and challenges.(Reference Stotz, Budd Nugent and Ridberg48) Given the numerous demands on paediatric clinics and staff, it may be unreasonable to expect consistent in-person education regarding a paediatric FVPP without one dedicated staff member on-site. Although posters and pamphlets, which described vendor addresses, hours of operation, and redemption procedures, were available at the partnering clinic, many caregivers remained unclear about participating vendors and redemption procedures. Some admitted that this lack of programme understanding negatively influenced their engagement in the programme.
Studies among adults who participated in fruit and vegetable incentive programmes have highlighted several barriers to engagement, including insufficient redemption/vendor sites(Reference Calo, Marin and Aumiller49–Reference Masci, Schoonover and Vermont51) and lack of transportation.(Reference Garner, Coombs and Savoie-Roskos47,Reference Caron-Roy, Sayed and Milaney52) Caregivers in the current study reported similar challenges that prevented them from engaging in the paediatric FVPP with their children. The FVPP partnered with Flint Fresh (Flint Fresh | Fresh Vegetable & Fruit Delivery in Flint) in January 2018 to preserve produce selection capacity while directly addressing transportation barriers among participants. Flint Fresh is a food aggregation space for local farmers and provides free delivery of participant-selected $15 and $30 fresh produce boxes. Unfortunately, few participants were aware of this option which resulted in underutilisation of prescriptions at this redemption site. Additionally, some shared confusion when attempting to navigate the farmers’ market and Flint Fresh website, highlighting a need for programme education at vendor sites and clinics. Future research will explore the impact of a community health worker, who specifically addresses challenges with programme education at both clinic and vendor sites, in improving engagement in the paediatric FVPP.
In February 2024, one major chain grocery store in Michigan partnered with the FVPP to accept fruit and vegetable prescriptions at seven of its stores in Flint and surrounding areas. Patients at Akpinar Children’s Clinic may now select Flint Farmers’ Market, Flint Fresh or Meijer grocery stores to redeem their prescriptions. Printed prescriptions may be redeemed at the pharmacy counter at Meijer stores in exchange for $15 fresh fruit and vegetable vouchers. Early results suggest this option has greatly improved engagement in the FVPP, and caregivers have expressed consistently positive experiences with the additional redemption site. The partnership was in direct response to caregiver feedback regarding the need for inclusion of at least one major chain grocery store where families may redeem prescriptions while shopping for other food items for their families.
Unlike most prescription programmes, participation in nutrition education activities was not required by the paediatric FVPP in the current study. Most caregivers indicated a desire for recipes or cooking classes to accompany prescriptions. Some requested cooking classes centred around children to teach culinary skills together with nutrition education. Others felt they would benefit from a culinary programme that focused on the fruits and vegetables that were purchased with prescriptions. Findings are consistent with earlier studies among adult and youth participants in FVPPs(Reference Saxe-Custack, Lofton and Hanna-Attisha31,Reference Calo, Marin and Aumiller49) and speak to a growing need for culinary support programmes. In direct response to early feedback from FVPP participants regarding a need for culinary programmes for youth,(Reference Saxe-Custack, Lofton and Hanna-Attisha31) Flint Kids Cook was developed in 2017.(Reference Saxe-Custack, Goldsworthy and Lofton53) Flint Kids Cook is a free six-week cooking and nutrition programme for youth (aged 8–18 years) taught by a professional chef and registered dietitian in a farmers’ market kitchen. Results suggest that participation in Flint Kids Cook is associated with significant improvements in cooking attitudes, cooking self-efficacy, and health-related quality of life of participating youth.(Reference Saxe-Custack, LaChance and Hanna-Attisha54) A virtual version of the class, Flint Families Cook, launched in 2021 with results suggesting programme participation was associated with improvements in cooking self-efficacy, health-related quality of life, and dietary behaviours.(Reference Saxe-Custack and Egan55,Reference Saxe-Custack, Egan and Sadler56) Over 500 youth have graduated from Flint Kids Cook with nearly 300 children waiting to participate. All paediatric clinics offering the FVPP advertise Flint Kids Cook through posters and brochures in waiting areas and patient rooms.
Finally, caregivers provided tangible recommendations to improve overall engagement in the paediatric FVPP. Some suggestions, including text or email reminders when prescriptions were set to expire, would be relatively easy to implement and have been reported in earlier qualitative studies with adults.(Reference Calo, Marin and Aumiller49) Other suggestions, including partnerships with large grocery store chains and digitising paper prescriptions, would require significant changes that may be costly to implement and require dedicated staff and procedural changes. Unfortunately, sustainable funding sources that allow produce prescription programmes to invest in these more costly initiatives to improve programme engagement are limited. Given the potential of paediatric FVPPs as a strategy to address inequities in food access in a broadly scalable manner,(Reference Virudachalam, Kim and Seligman25) substantial investment in continued programme improvements is warranted.
This current study has limitations. It was small and limited to one urban community in Michigan. Results may not be generalisable. As previously mentioned, because only one child and one caregiver enrolled into the original study, researchers were unable to accurately quantify the total number of prescriptions received and redeemed by each household. Finally, it is possible that views of the programme and challenges with redemption differed among participants researchers did not reach for interviews. However, participants were candid about their programme experiences and barriers to redemption. Each offered important feedback to improve overall engagement.
Conclusions
The potential impact of fruit and vegetable prescription programmes focused on paediatric patients is substantial. In addition to recent studies indicating a positive influence on caregiver- and child-reported food security,(Reference Saxe-Custack, LaChance and Jess21,Reference Ridberg, Bell and Merritt24) food shopping,(Reference Saxe-Custack, Sadler and LaChance26) and dietary behaviours of children,(Reference Saxe-Custack, LaChance and Jess21,Reference Saxe-Custack, LaChance and Hanna-Attisha27–Reference Buscail, Margat and Petit30) these programmes offer notable benefits to all household members who consume produce purchased with prescriptions. Crucial to the success of these programmes, however, is the understanding of barriers to engagement among programme participants and their families. The current study elucidates challenges with one paediatric FVPP and provides actionable solutions, from the viewpoint of caregivers, to address these challenges. Future research will investigate whether and how expansion to full-service grocery stores and development of digital prescriptions impact programme engagement.
Abbreviations
FVPP: Fruit and vegetable prescription programme; EMR: Electronic medical record; SCT: Social Cognitive Theory.
Financial support
This work was supported by the Michigan Health Endowment Fund (grant number R-2003-145864). Michigan Health Endowment Fund had no role in the design, analysis or writing of this article.
Competing interests
The authors declare none.
Authorship
A.S.-C. conceived the study, study design and analysis; led analysis of the data; and led all writing and drafting of the manuscript. S.E. participated in data collection and analysis; and contributed to drafting and revising of the manuscript. B.F. and K.P. participated in data collection and analysis; and participated in revising of the manuscript. A.S. assisted with data preparation and participated in drafting and revising of the manuscript. All authors have approved the final article.
Open access
