A mixed methods analysis to explore retention in the Fruit and Vegetable Prescription (FVRx) program from Grady Hospital, Open Hand, and Wholesome Wave Georgia Open Access

Abstract

Food insecurity is defined as the lack of physical, social, and economic access to sufficient, safe, and nutritious food. In 2019, 10.5% of US households were food insecure at some point. The Fruit and Vegetable Prescription Program at Grady Health System (G-FVRx) is a program managed by Wholesome Wave to increase access to affordable produce among food insecure communities in Atlanta, Georgia. A mixed method approach was used to describe strategies for recruitment and retention in the program and presents predictors of loss to follow-up. Baseline characteristics were compared between those who graduated from the program to those who did not using chi squared tests. Logistic regression was used to examine the association between baseline age, sex, BMI, controlled diabetes, hypertension, employment status, education level, food security scores, SNAP benefits, income status, and attitudes around food intake and cooking behaviors and loss to follow up. Cohort clinic site (P=0.007), age (P=0.001), BMI (P=0.037) and baseline food security (P=0.0243) showed a statistically significant difference between those who graduated and those lost to follow up. Older age (p=0.0035) and being enrolled at any cohort clinic site compared to Grady Infectious Disease Program (P=0.0243) were protective against loss to follow up, while having “very low” food security compared to “high” food security was predictive (P=0.0299). Qualitative data was collected via key informants from different partners and participants in the G-FVRx program to understand factors of retention, as well as to identify areas of improvement for future programming. The main topics that emerged included patient centered approach, social support, challenges to program implementation, external barriers and recommendations and programmatic improvements. Recommendations for next steps include increasing focus on cultural relevance and diversity within the G-FVRx course content and cooking sessions to address food choices, partnering with local grocery stores to provide produce for participants which would increase access to healthy foods, provide shuttles or carpools for participants to attend classes and appointments, enhance peer support groups and peer champions, and future qualitative and quantitative analyses including participants who were lost to follow up to gain further perspectives as to ways to improve retention.

Table of Contents

EXECUTIVE SUMMARY.....................................................................................................1

Project Context................................................................................................................ 1

Project Aims.................................................................................................................... 1

Methods.......................................................................................................................... 1

Key Findings.................................................................................................................... 2

Recommendations............................................................................................................ 2

LIST OF ACRONYMS........................................................................................................ 3

LITERATURE REVIEW...................................................................................................... 4

The problem of food insecurity.. ........................................................................................4

Food insecurity, nutritional status, and chronic disease risk................................................. 5

Implementation science.................................................................................................... 7

Social Ecological Model .................................................................................................... 8

Fruit and vegetable prescription programs ......................................................................... 10

Wholesome Wave Rx.........................................................................................................11

Impacts and challenges of produce Rx programs................................................................ 12

Strategies for retention.....................................................................................................17

Conclusion.......................................................................................................................18

TABLE............................................................................................................................. 20

1: Comparison of peer reviewed fruits and vegetable prescription Programs..........................20

ABSTRACT....................................................................................................................... 26

INTRODUCTION............................................................................................................... 27

METHODS........................................................................................................................30

Study sites...................................................................................................................... . 30

Research design ................................................................................................................31

Sample size and sampling strategy for qualitative research...................................................31

Recruitment of interviewees ............................................................................................. 31

Data collection instrument................................................................................................ 32

Quantitative analysis of determinants of retention ............................................................. 32

Data analysis and management. .........................................................................................34

Strategies for protection of human right. ............................................................................35

RESULTS...........................................................................................................................35

Participant characteristics................................................................................................. 35

Indicators of loss to follow up............................................................................................ 36

QUALITATIVE ANALYSIS................................................................................................... 37

Patient Centered Approach................................................................................................ 38

Social Support.................................................................................................................. 41

Challenges to Program Implementation............................................................................. 43

External Barriers............................................................................................................... 46

Recommendations and Programmatic Improvements...........................................................49

TABLES............................................................................................................................ 51

1: Retention Rate Across Clinic Sites...................................................................................51

2: Descriptive Characteristics............................................................................................. 52

3: Bivariate Factors Associated with Loss to Follow-Up.........................................................55

4: Age and Sex Adjusted Factors Associated with Loss to Follow-Up.......................................57

5: Summary of Key Qualitative Themes...............................................................................59

ARTS BASED METHODS.................................................................................................... 61

DISCUSSION.................................................................................................................... 81

SUMMARY OF KEY FINDINGS........................................................................................... 81

Summary of Key Findings...................................................................................................81

Limitations.......................................................................................................................83

Recommendations ............................................................................................................84

Next steps........................................................................................................................ 85

PUBLIC HEALTH IMPLICATION..........................................................................................87

LITERATURE CITED...........................................................................................................87

APPENDICES.................................................................................................................... 94

Stakeholder interview guide .............................................................................................. 94

Participant interview guide ............................................................................................... 96

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Nutrition Health Sciences, General
Keyword	Public Health Food Insecurity Retention
Committee Chair / Thesis Advisor	Girard, Amy Webb, Emory University
Committee Members	Gujral, Unjali, Emory University Andes, Karen, Emory University

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