The nutrients in fruits and vegetables are critical for proper growth and development( Reference Albani, Butler and Traill 1 – Reference Prynne, Mishra and O’Connell 3 ), cognitive function( Reference Cohen, Gorski and Gruber 4 ) and chronic disease prevention( Reference McCormack, Laska and Larson 5 – Reference Maynard, Gunnell and Emmett 9 ). Unfortunately, children living in the USA consume fewer servings than recommended, particularly those living in low-income households( Reference Drewnowski and Rehm 10 – Reference Dannefer, Abrami and Rapoport 12 ). With fruit and vegetable intake tracking from childhood to adulthood( Reference Di Noia and Byrd-Bredbenner 11 , Reference Li and Wang 13 ), it is important that health-care professionals guide children towards healthy eating early. However, challenges related to fruit and vegetable access and affordability must be considered alongside nutrition education( Reference Carty, Mainvil and Coveney 14 , Reference Kamphuis, Giskes and de Bruijn 15 ). Innovative efforts such as farmers’ market incentive programmes, designed to increase affordability of fresh produce, have demonstrated success in improving fruit and vegetable intake among adults( Reference Savoie-Roskos, Durward and Jeweks 16 , Reference Lindsay, Lambert and Penn 17 ). More recently, health-care practices have launched fruit and vegetable prescription programmes( Reference Buyuktuncer, Kearney and Ryan 18 – Reference Bryce, Guajardo and Ilarraza 20 ). Similar to medical prescriptions, these are written by health-care providers in exchange for fresh produce.
Thus far, few studies have examined perceptions of fruit and vegetable prescription programmes among adults( Reference Buyuktuncer, Kearney and Ryan 18 , Reference Kearney, Bradbury and Ellahi 19 ) and none have assessed experiences with programmes that target underserved children. Previous research has shown that participation in fruit and vegetable prescription programmes is associated with an increased awareness of the connection between food and health as well as improved management of chronic conditions( Reference Buyuktuncer, Kearney and Ryan 18 – Reference Bryce, Guajardo and Ilarraza 20 ). However, evidence also suggests that prescription programmes targeting adults do not significantly improve the purchase and consumption of fresh produce( Reference Buyuktuncer, Kearney and Ryan 18 , Reference Kearney, Bradbury and Ellahi 19 ). To gain a better understanding of how farmers’ market fruit and vegetable prescription programmes impact consumption patterns, particularly among low-income families, an investigation of participant experiences in these programmes is necessary. The current study sought to explore caregiver perceptions of an urban paediatric clinic co-locating with a farmers’ market, experiences with a fruit and vegetable prescription programme and perceived impact of these initiatives on child consumption of fruits and vegetables.
Methods
Study setting
Approximately 60 % of children in Flint, Michigan, USA are living in poverty( Reference Guevara Warren 21 ) and a limited number of full-service grocery stores operate within city limits( Reference Zahran, McElmurry and Sadler 22 ). Lacking resources and nutritional options, many children experience the double burden of insufficient intake of nutrient-dense foods coupled with high intake of poor-quality, energy-dense foods. In addition to the enduring issues related to food access, the city is currently experiencing a public health crisis with Pb contamination of the water supply, which is aggravated by poor nutrition( Reference Hanna-Attisha, LaChance and Sadler 23 – Reference Wright, Tsaih and Schwartz 27 ). In August 2015, Hurley Children’s Center (HCC), a Michigan State University-affiliated residency training paediatric clinic with over 11 000 visits each year, relocated to the second floor of the downtown Flint Farmers’ Market (FFM). The FFM is a year-round market with over fifty vendors located inside and outside the farmers’ market building. Vendors are primarily local farmers who sell fresh produce, but the FFM also offers a meat market, poultry, breads and baked goods, cheese and several restaurants. The market is open to the public on Tuesday, Thursday and Saturday.
Immediately following the ground-breaking and unprecedented move of HCC to the FFM, the two organizations partnered to establish a farmers’ market fruit and vegetable prescription programme. The prescription programme began as a pilot with support from Michigan Department of Health and Human Services, and is currently funded by Rite Aid Foundation. Similar to medical prescriptions, the fruit and vegetable prescriptions are written by physicians and given to patients. All HCC patients receive a $US 10 fruit and vegetable prescription at every clinic visit to be redeemed for fresh produce at the FFM. Vendors treat the prescriptions as gift certificates or vouchers that can only be redeemed for fresh fruits and vegetables. The vendors stamp prescriptions as redeemed and submit the redeemed prescriptions to the FFM management office, which then pays the vendors for the redeemed prescriptions. When the FFM is closed, families have the option of receiving either the $US 10 prescription or a vendor-prepared bag of fresh fruits and vegetables.
Approach and theoretical framework
Given the specific interest in understanding caregiver experiences with clinic relocation and the prescription programme, a qualitative approach was deemed appropriate. Qualitative research seeks to understand and interpret personal experiences, give voices to those who are rarely heard and provide rich descriptions of complex phenomena (including those related to health)( Reference Huston and Rowan 28 – Reference Sofaer 30 ). The current study was researched with narrative qualitative methodology, which is primarily used to investigate and appropriately account for a particular experience of a designated population( Reference Clandinin and Connelly 31 ). Narrative inquiry allowed researchers to use field text, in the form of interviews, to understand the narration of individuals and their experiences with the initiatives( Reference Clandinin and Connelly 31 ).
The design and approach of the study were grounded in the theoretical framework of Bandura’s Social Cognitive Theory( Reference Montgomery 32 , Reference Bandura 33 ). Social Cognitive Theory describes behaviour change as an interaction between personal, behavioural and environmental factors( Reference Berlin, Norris and Kolodinsky 34 ). Collaborating with physicians at HCC and agricultural leaders and advocates, the framework of Social Cognitive Theory supported a sub-focus on environmental change. Since children are generally guided by parents in their dietary intake, environmental factors, such as access to healthy foods and caregiver modelling, were of critical importance( Reference Nixon, Moore and Douthwaite 35 – Reference Birch and Fisher 38 ). By supporting the study with the theoretical framework of Social Cognitive Theory, researchers were able to integrate the core concepts to better elucidate caregiver experiences.
Data collection
Following the qualitative narrative approach, researchers collected data via semi-structured interviews between February 2017 and April 2017. During scheduled clinic visits, researchers purposively sampled caregivers who self-reported that their child had received a fruit and vegetable prescription. Caregivers were eligible to participate if (i) their child had received at least one fruit and vegetable prescription, (ii) they completed a screening questionnaire and (iii) they spoke English. A total of 106 caregivers were eligible and provided written informed consent. These caregivers then scheduled either an in-person or telephone interview with a researcher. Researchers attempted reminder calls to all 106 caregivers, yet data collection was challenged by poor attendance at scheduled interviews, a problem exacerbated by disconnected or non-working telephone numbers. After successfully completing thirty-two interviews, researchers terminated enrolment and data collection based on a joint conclusion that no additional concepts were being observed. According to previous research on thematic analysis, data can often reach saturation during sampling( Reference Ando, Cousins and Young 39 ). Participants received a $US 30 gift card to the FFM after completing the interviews, which varied in length from 20 to 45 min.
The research team developed an open-ended interview format to assess caregiver perceptions of HCC’s relocation; experiences with the fruit and vegetable prescription programme; opinions of the FFM; impact on child consumption of fresh produce; and suggestions for improvement. Two members of the research team, trained in qualitative research methods, independently facilitated the interviews. Questions such as ‘Tell me about your experiences with Hurley Children’s Center’s move to the Flint Farmers’ Market building’ invited conversation regarding the benefits and barriers of HCC co-locating with the FFM, while more involved questions such as ‘How (if at all) did participation in the prescription programme impact your child’s intake of fresh fruits and vegetables?’ probed about experiences related to access and consumption of fresh fruits and vegetables. Researchers had the flexibility to gather additional information based on the interview guide (Table 1), which was developed using existing literature( Reference Buyuktuncer, Kearney and Ryan 18 , Reference Wetherill and Gray 40 – Reference Olsho, Payne and Walker 42 ), research questions and researchers’ experiences with the topic and population.
Table 1 Semi-structured interview guide
Data analysis
Audio recordings from the interviews were transcribed verbatim for textual data analysis. Using a multistep coding process, guided by thematic analysis( Reference Braun and Clarke 43 – Reference Braun and Clarke 45 ), researchers examined data to uncover and analyse patterns across transcripts, formulating illustrative themes( Reference Thomas and Harden 46 ). First, three researchers performed an initial coding process, individually highlighting, labelling and developing potential categories for thematic purposes. Next, they discussed the deductive themes, influenced by interview questions 5 and 6 from the semi-structured interview guide (Table 1). The theme ‘perceived impact of combined interventions’, and accompanying sub-themes, serves as a deductive theme. All other themes were inductive and data-driven, therefore emerging themes. Researchers eliminated less reflective themes and collapsed similar themes. Finally, two researchers selected explanatory quotations to support the final themes and sub-themes, conclusively determining an illustrative coding scheme.
Researchers received institutional review board approvals from Michigan State University and Hurley Medical Center.
Results
Among the thirty-two interview participants (mean age 36·6 (sd 11·7) years), the majority were female (91 %) and African American (53 %), and the mean number of children living in the household was three.
After thirty-two participants completed either an in-person (n 15) or telephone (n 17) interview, it was noted that no new information was forthcoming and data saturation was reached. Presented below are the findings of the following recurrent themes that emerged during interviews: (i) convenience of clinic relocation; (ii) attitude towards fruit and vegetable prescription programme; (iii) challenges with implementation; and (iv) perceived impact of combined interventions. These themes are organized in Table 2 according to associated sub-themes.
Table 2 Illustrative quotes for themes and sub-themes related to caregiver perceptions of a fruit and vegetable prescription programme for low-income paediatric patients, Flint, Michigan, USA
FFM, Flint Farmers’ Market.
* Quote attributions are presented as (race/ethnicity/sex,#,#C), where AF=African-American female, #=age in years, #C=number of children, CF=Caucasian female and CM=Caucasian male.
Convenience of clinic relocation
HCC’s relocation was predominantly discussed with emphasis on the new level of convenience caregivers experienced. Previously, HCC was adjacent to Hurley Medical Center in Flint, away from the downtown area and central hub for transportation. Currently, it is across the street from the central bus station and nearby downtown. In terms of distance to home, bus station or the FFM, the new central location proved to be an asset (Table 2, sub-theme 1.1). Many caregivers specifically mentioned that the clinic was now within walking distance of their home, while others praised the new location in relation to accessing the bus station:
‘It [clinic relocation] is perfect. It is only ten minutes from my house.’ (Caucasian female, age 37 years, with four children)
‘I like it better over here – it’s closer and it’s convenient … because the bus station is near and I have to take them [children] on the bus.’ (African-American female, aged 52 years, with two children)
Caregivers specifically discussed the convenience of the clinic co-location with a farmers’ market (Table 2, sub-theme 1.2). Many indicated that they typically buy groceries with their children and are now able to save transportation time by visiting the FFM before or after clinic visits. In fact, some caregivers shared that they shopped at the FFM only because of its co-location with HCC:
‘I think we come a lot extra with the doctors being here now. Where before we would have to go out of our way to go to the farmers’ market. Now, it’s there, it’s convenient, we’re in the same parking lot, we just go from this door to that door.’ (Caucasian female, age 32 years, with one child)
‘Well, honestly it was the first time that I have ever been to the Flint Farmers’ Market, since the clinic has been in their new building. If they [clinic] weren’t connected right to it, I honestly don’t think I would go there.’ (Caucasian female, age 28 years, with three children)
Attitude towards fruit and vegetable prescription programme
Caregivers expressed an overwhelming appreciation for the prescription programme (Table 2, sub-theme 2.1). Every caregiver had a positive view of the programme, and most discussed their deep gratitude towards paediatricians for supporting families beyond traditional medical care. Many indicated that they had limited resources and the prescriptions helped them acquire healthy food. Others were thankful that their children were offered fruits and vegetables rather than ‘treats’ that often follow visits to the paediatrician:
‘I was surprised that they were doing that [prescriptions], and I was touched too because that shows that they are really thinking about the people that they serve. It goes beyond just taking care of us … it feels like they genuinely care about us. So, that meant a lot. (African-American female, age 35 years, with one child)
‘I just think it’s great. It’s great for families that are struggling and don’t get to experience the farmers’ market. Because you have to have extra money to come here … Ten dollars, that’s a lot when you have nothing.’ (Caucasian female, age 32 years, with one child)
As caregivers reflected on the redemption of prescriptions at the FFM, interactions with the vendors surfaced as an important aspect of the experience (Table 2, sub-theme 2.2). The majority of caregivers discussed their fondness for farmers’ market vendors, both those who accepted the prescriptions and those who did not. Vendors were considered friendly and helpful, and assisted caregivers and children in receiving the appropriate amount of produce. Additionally, caregivers expressed having a seamless experience with prescription redemption:
‘It was simple. I picked out what I wanted, gave it to them and whatever was left … If I had enough for something else, they would tell me. It was a piece of cake.’ (Caucasian female, age 34 years, with three children)
‘They [vendors] were very friendly and very helpful. And they were very generous ... They make it easy to get fresh fruits and vegetables. He [vendor] said, “You come back, and I will treat you right.” And they always do.’ (African-American female, age 61 years, with one child)
Vendor-prepared produce bags were offered as an alternative to fruit and vegetable prescriptions when the FFM was closed. The majority of caregivers indicated that they preferred the prescriptions to the produce bags (Table 2, sub-theme 2.3). Caregivers discussed how prescriptions allowed children to both enjoy the farmers’ market and select their own fruits and vegetables. Some even mentioned that they scheduled HCC visits based upon their preference for prescriptions:
‘I’d rather do the prescription. Because sometimes stuff in the bag, it’s useful, but I find it easier for me to go and do my own shopping. Let the kids do their own shopping.’ (Caucasian female, age 35 years, with four children)
‘When I was first bringing him [son] it was on Monday, so now I try to make his appointments on Tuesdays, so we can go straight downstairs and he can pick out his own fruits and vegetables.’ (African-American female, age 53 years, with five children)
Challenges with implementation
Although caregivers had strong positive views of the prescription programme, there were a few implementation challenges. The majority of caregivers indicated that they were given a produce bag without the option of receiving a fruit and vegetable prescription when the FFM was closed (Table 2, sub-theme 3.1). When probed further, most indicated that their families consumed most or all of the bags’ contents, but they much preferred the fruit and vegetable prescriptions. Although caregivers expressed a strong appreciation for the produce bags, the majority were entirely unaware they could request a fruit and vegetable prescription in lieu of the bag:
‘Usually, they just come in with the bag. There has not been an either or [bag or prescription] … usually it seems like the days the market is closed, we get the bags.’ (Caucasian male, age 37 years, with two children)
‘They just gave me the bag. I didn’t get prescriptions this time.’ (African-American female, age 29 years, with four children)
Inconsistent distribution of prescriptions and/or produce bags was another challenge to proper implementation (Table 2, sub-theme 3.2). Most caregivers indicated that the programme was very easy to comprehend. However, when asked about specifics, the majority did not know the intended frequency of distribution:
‘It was just our latest doctor’s visit, that was our first time [receiving a prescription]. We have been at this clinic for eighteen months, and we have only received one prescription. So, I still don’t really know how it works. (Caucasian female, age 31 years, with three children)
‘Actually, the girls came here last year, I do believe. I never, I didn’t get no fruits and vegetables when they had their physical last year.’ (African-American female, age 36 years, with five children)
Finally, some caregivers expressed frustration with navigating the FFM (Table 2, sub-theme 3.3). Although most found vendors to be helpful, some said they were not told at the clinic which vendors accepted the prescriptions. Additionally, several mothers with small children preferred grocery store shopping with carts to hold their children and centrally located food:
‘A doctor told me that they were giving me a coupon for over there. And I went, and I was wondering who took it.’ (African-American female, age 59 years, with two children)
‘Just really ain’t had no time to go to the farmers’ market ’cause my kids are so young. So, it’s kind of hard to go when you got different stands to look at. When you go into the actual grocery store, everything is right there … They only went with me one time, and they were running all around. I said it would be easier for me to go to the grocery store, so I could be in one section.’ (African-American female, age 24 years, with three children)
When asked about suggestions to improve the fruit and vegetable prescription programme, many caregivers asked for assistance with food preparation (Table 2, sub-theme 3.4). Some suggested that HCC work with the FFM to develop programmes and recipes to support families in preparing the foods that they purchase with the fruit and vegetable prescriptions:
‘Well, sometime you could give them [children] a seminar or a class or something on how to incorporate the fruits and vegetables. How to fix different dishes ’cause a lot of these young kids can’t cook.’ (African-American female, age 61 years, with one child)
‘It’s not just the access but teaching people how to eat healthy and how easy it could be to prepare your own meals … so maybe something like that could be available for parents.’ (Caucasian female, age 37 years, with one child)
Perceived impact of combined interventions
During the interviews, many caregivers discussed food security issues, describing continual challenges with the cost of food (Table 2, sub-theme 4.1). Some indicated that adult family members may go without food. Others who did not qualify for government assistance struggled to purchase fruits and vegetables with limited financial resources. Many caregivers indicated that the prescription programme had been extremely helpful, particularly in times of need. Some even discussed saving prescriptions until they reached a specific dollar amount:
‘We struggle like hell with food. If it wasn’t for the grandparents helping us out here and there, me and my husband would basically be the ones not eating every day.’ (Caucasian female, age 34 years, with three children)
‘When, if I run out of cash or food stamps, then I always have those [prescriptions] … I save some of them, hold onto them for when I need them. Like I said, when I run out of food stamps and stuff like that, I can still come and get the kids fruits and stuff.’ (African-American female, age 52 years, with two children)
The majority of caregivers discussed that the combined initiatives (relocation and prescription programme) facilitated access to fresh, high-quality produce (Table 2, sub-theme 4.2). Many mentioned that grocery stores in their area carried spoiled or poor-quality fruit but consistently noted the superior quality of the FFM’s produce:
‘Some people … live quite a bit away, but they still come downstairs [to the FFM] to just have some fresh fruit. You ain’t gotta worry about nothing being mouldy, you ain’t gotta worry about something being outdated, you know, or picked through. Because when you go down there, everything is in order. So, it’s really good.’ (African-American female, age 36 years, with five children)
‘Most of the time in the grocery stores, the [fruits and vegetables] are bruised and bad. Almost like they need a better selection. They are much better here [farmers’ market].’ (African-American female, age not disclosed, with five children)
The combined initiatives allowed caregivers to provide healthier options and introduce children to a variety of fresh fruits and vegetables (Table 2, sub-theme 4.3). Many indicated that the programme had a noticeable impact on their child’s fruit and vegetable intake, highlighting an increased acceptance of fresh produce. The prescriptions were especially appreciated for their ability to provide children the autonomy to choose their own fruits and vegetables. Many caregivers reported that after their first prescription, visiting the market and selecting produce with their children became a common practice that invited further discussion of growing and preparing fresh foods:
‘They had a thing called a tangelo … [S]he loved that. And she needs more of those she said. (Caucasian female, age 32 years, with one child)
‘I think they understood a lot more about where fruits and vegetables come from … [T]hey eat it all the time, but they don’t understand that it comes off a plant or a tree.’ (African-American female, age 59 years, with two children)
Discussion
The present study is the first to examine caregiver perceptions of a fruit and vegetable prescription programme offered at a paediatric clinic. Central to our findings was the perceived impact of the prescription programme on food security. HCC is an urban paediatric clinic that serves primarily low-income children and families. Although not surprising that families discussed ongoing challenges with food access and affordability, feedback indicated the critical importance of the prescription programme in combatting food insecurity. Many described saving prescriptions to reach a higher dollar amount, while others discussed the importance of the prescriptions when dollars or food benefits were scarce. Although food insecurity in children has been associated with negative health outcomes( Reference Casey, Simpson and Gossett 47 – Reference Metallinos-Katsaras, Must and Gorman 49 ) and poor academic achievement( Reference Faught, Williams and Willows 50 ), primary care providers often do not play an active role in addressing the underlying problem( Reference DeMartini, Beck and Kahn 41 ). The current study suggests that primary care providers can and should address patients’ food security issues in an effort to prevent associated outcomes.
In addition to food insecurity, most caregivers talked extensively about the poor quality of produce available to them. It has been well documented that low-income neighbourhoods have lower-quality food and fewer healthy food options than higher-income neighbourhoods( Reference Zenk, Odoms-Young and Dallas 51 – Reference Baker, Schootman and Barnidge 53 ). Furthermore, previous studies have reported that the primary barriers to consuming fresh produce are poor-quality fresh fruits and vegetables as well as limited money available to spend on food( Reference Buyuktuncer, Kearney and Ryan 18 ). Caregivers in the current study described local stores with spoiled or mouldy fruits, whereas the farmers’ market offered a wide variety of fresh, high-quality produce. Previous research addressing food access challenges in Flint, Michigan has presented similar findings( Reference Mayfield, Carolan and Weatherspoon 54 ). The partnership between HCC and the FFM is one example of creative efforts that could be modelled in low-income areas to improve access to high-quality produce.
Although previous studies focused on low-income adults have found that participation in fruit and vegetable prescription programmes does not significantly change consumption or purchasing behaviour( Reference Buyuktuncer, Kearney and Ryan 18 ), the current study suggests that caregivers perceived the prescription programme to have a significant impact on child intake of fresh produce. Caregivers discussed using the prescriptions to purchase ‘new’ fruits and vegetables that children had not previously tasted. Additionally, most believed that participation in the programme increased their child’s consumption of fruits and vegetables because children were able to choose the items they preferred. Some even described children tasting fruits and vegetables at the farmers’ market and using prescriptions to purchase the produce they liked best.
The current study supports previous research indicating that child participation in food selection and preparation is effective in improving diet quality( Reference Chu, Storey and Veugelers 55 – Reference Hersch, Perdue and Ambroz 58 ). Caregivers preferred prescriptions over produce bags primarily because children enjoyed selecting their own fruits and vegetables. Although no previous studies have examined a similar model of prescription distribution with children, research focused on food pantries has demonstrated that clients prefer a ‘choice’ food pantry, which includes client food selection, over the traditional box or bag of pre-selected items( Reference Remley, Zubieta and Lambea 59 ). Caregivers in the current study discussed the importance of choice when using prescriptions v. produce bags, indicating that prescriptions prevented food waste that often occurred when families received unwanted food in produce bags. This finding is similar to food pantry research demonstrating a perceived decrease in food waste resulting from a ‘choice’ food pantry( Reference Remley, Zubieta and Lambea 59 ). In addition, caregivers requested that cooking classes be offered to assist families with food preparation. Many discussed challenges with preparing fresh vegetables in particular and indicated that children frequently chose fruits with their prescriptions because vegetables were less familiar and difficult to cook. This finding is particularly important as evidence consistently reports that vegetables are poorly accepted among children( Reference Fisher and Dwyer 60 – Reference Kim, Moore and Galuska 62 ) and intake fails to meet recommendations( Reference McGuire 63 ).
Recognizing that produce bags were provided when the FFM was closed, the current study does not support previous research indicating that limited operating hours are a barrier to farmers’ market shopping( Reference Wetherill and Gray 40 , Reference Savoie Roskos, Wengreen and Gast 64 ). There were only two weekdays that families could visit both HCC and the FFM. However, when probed about the limited business hours, nearly all caregivers responded that the hours were not a deterrent to farmers’ market shopping. Some responded that, in an effort to share the shopping experience with their children, they now schedule HCC appointments when the FFM is open. Most of the caregivers indicated that their children enjoyed shopping at the FFM, particularly when carrying the $US 10 prescriptions to purchase their own fruits and vegetables.
Caregivers viewed the clinic relocation positively, noting HCC’s proximity to the FFM, bus station and the centre of town. Additionally, many discussed their strong appreciation towards paediatricians and staff for providing services beyond traditional medical care. Interestingly, some caregivers also discussed improvements in medical services they perceived to be related to the relocation, such as higher quality of care and quicker scheduling of sick visits. Among the major aims for improving health care is patient-centred treatment, such that health care focuses on patient preferences, needs and values – including addressing underlying social determinants of health( Reference Harolds 65 ). Initiatives such as those described in the current study may not only assist with food security and access, but also improve caregiver perceptions of the overall quality of care.
Although the fruit and vegetable prescription programme was viewed positively, caregivers discussed challenges with implementation and offered suggestions for improvement. In response to the feedback regarding implementation challenges, HCC developed marketing materials to advertise the prescription programme, qualifying vendors and distribution frequency. To address caregiver suggestions related to food preparation, HCC partnered with the FFM to develop, implement and evaluate a cooking and nutrition education class for children at the FFM. These classes, co-taught by the FFM culinary director and HCC dietitian, focus on foods that may be purchased using the fruit and vegetable prescriptions.
Limitations of the current study should be acknowledged. There may have been selection bias as feedback from families who chose not to participate may differ from those who agreed to share their experiences. The present study specifically examined caregiver experiences with two initiatives focused on improving access, availability and affordability of fresh fruits and vegetables. The sample size was small and specific to one paediatric clinic. Therefore, results may not be generalizable to a broader population. However, fruit and vegetable prescription programmes could certainly be modelled in areas confronted with similar challenges related to access and affordability of fresh foods. Furthermore, considering the call by the global nutrition community for programmes to address the dual burden of undernutrition and obesity( Reference Jaacks, Kavle and Perry 66 ), as well as increasing evidence of unhealthy food practices among young people in low- and middle-income countries( Reference Verstraeten, Leroy and Pieniak 67 , Reference Nago, Lachat and Huybregts 68 ), fruit and vegetable prescription programmes may be an important tool to link locally grown fruits and vegetables with health systems.
Conclusions
Because income is positively associated with fruit and vegetable consumption, low-income children may experience particular benefit from incentive programmes designed to improve overall intake( Reference Di Noia and Byrd-Bredbenner 11 ). The current study demonstrates that partnerships between farmers’ markets and primary care clinics in areas where access to fresh food is scarce are perceived as effective in improving food security, food access and consumption in relation to fruits and vegetables. Future research will examine quantitative data, in the form of prescription fill rates, dietary recall and food security assessments, to measure reported changes resulting from interventions.
Acknowledgements
Financial support: Support for the Hurley Foundation has been provided by the Metabolic Studio, a direct charitable activity of the Annenberg Foundation (M.H.-A., grant number 16-404). This support funded the current research project. The fruit and vegetable prescription programme was supported by grants from the Michigan Department of Health and Human Services (M.H.-A., grant number 20162174) and Rite Aid Foundation (M.H.A.). The Metabolic Studio; Michigan Department of Health and Human Services; and Rite-Aid Foundation had no role in the design, analysis or writing of this article. Conflict of interest: None. Authorship: A.S.-C. conceived the study, study design and analysis; collected data; led analysis of the data; and led all writing and drafting of the manuscript. H.C.L. participated in data collection and analysis; and contributed significantly to interpretation of results and drafting of the manuscript. M.H.-A. developed the fruit and vegetable prescription programme; and assisted in conceptualization of the study and the drafting and revising of the manuscript. C.V. recruited participants into the study; participated in data analysis and interpretation of results; and contributed significantly to manuscript revisions. G.R., T.C. and J.L. each assisted in conceptualization of the study and the drafting and revising of the manuscript. Ethics of human subject participation: 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 institutional review boards of Michigan State University and Hurley Medical Center. Written informed consent was obtained from all subjects.
