Evaluation of a Produce Prescription Program for Low-Income Adults Open Access

Cook, Miranda (Fall 2021)

Permanent URL: https://etd.library.emory.edu/concern/etds/qj72p858b?locale=en


Despite the proliferation of produce prescription (PRx) programs seeking to address structural barriers to achieving high-quality diets, little evidence exists demonstrating effectiveness in underserved populations, program mechanisms of action, and the role stress plays in these interventions. The objective of this dissertation is to enhance understanding of the role of PRx programs in addressing the relationship between food insecurity, diet quality, and chronic disease by addressing these critical gaps. We used data collected from the Georgia Food for Health (GF4H) program, a 6-month PRx program implemented in an underserved population in Atlanta, Georgia. GF4H provides vouchers redeemable for produce alongside interactive nutrition and cooking education. Linear mixed models were used to estimate the association between monthly program visits attended (1-6) and health outcomes. Program participation was associated with significant reductions in BMI (p=0.04), waist circumference (p<0.001), systolic blood pressure (p<0.001), and diastolic blood pressure (0.001). Pathway analysis was used to estimate relationships between program intermediate educational outcomes and primary ones, revealing improvements in confidence with buying and cooking healthy food on a budget and food resource management practices such as comparing practices were the key drivers of diet change in the GF4H program. Lastly, in-depth interviews with program participants revealed two distinct typologies related to how participants experienced stress related to food insecurity: namely, those who described stress as overwhelming and those who described self-management of stress through internal processes. Regardless of typology, cost was described as a major barrier to acquiring desired amounts of fruits and vegetables. Making unhealthy eating decisions when stressed was described as comforting and precipitated by feelings of exhaustion and internal conflict. Program-related nutrition education and social support were described as facilitators of healthy eating. Collectively, this work demonstrates the association between PRx program participation and improvements in multiple chronic disease risk factors in a vulnerable, low-income population, highlights the importance of activities designed to increase self-efficacy and food resource management skills, and characterizes the lived experience of stress for PRx participants, emphasizing the role of group-education in achieving behavior change. 

Table of Contents

Chapter 1: Introduction 1

Research Aims 4

Chapter 2: Background 9

The Burden of Diet-related Chronic Diseases 9

Food Insecurity and Chronic Disease 18

Food Security Interventions 28

Chapter 3: Methods 55

Analytical approach & rationale for study aims 61

Chapter 4: Participation in a produce prescription program was associated with reductions in chronic disease risk factors in a low-income, urban population 68

Chapter 5: Changes in confidence & food resource management skills drive diet change in a produce prescription program: A multivariate pathway analysis 98

Chapter 6: Stress & food insecurity among participants of a clinic-based produce prescription program: Characterizing lived experiences. 122

Chapter 7: Discussion 147

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