Recipient Organization
CHILDREN'S NATIONAL MEDICAL CENTER
111 MICHIGAN AVE NW
WASHINGTON,DC 20010
Performing Department
(N/A)
Non Technical Summary
Almost 15% of US households with children reported experiencing food insecurity (FI) in 2020 and certain households are hit harder than others, including those led by a single parent, low-income, and racial/ethnic minoritized. This is a public health problem because FI is associated with poor diet quality and health and social outcomes across the lifespan. Produce prescription programs (PPP) targeting adults aim to address FI and diet quality but there are fewer programs reaching families with children. It remains unclear to what extent PPP interventions impact FI and healthy eating in families living in communities with limited access to healthy food and the best way to deliver these interventions. The Children's National Hospital Produce Prescription Initiative (FLiPRx) aims to address FI and diet-related disease risk in families with children living in under-resourced settings in Washington, DC. We have conducted formative work to show preliminary feasibility and promising behavioral outcomes to suggest the FLiPRx can potentially improve severity of household FI and fruit and vegetable intake in adults and children. However, we have made adjustments to our delivery and curriculum to address identified barriers to participant engagement. Our current aim is to evaluate FLiPRx feasibility and the effectiveness of the program on diet quality, FI, health and healthcare utilization and cost. Results from this work can help guide clinical care and policy decisions around how to effectively address social stressors that impact health in historically and economically marginalized populations.
Animal Health Component
45%
Research Effort Categories
Basic
45%
Applied
45%
Developmental
10%
Goals / Objectives
The overall goal of the proposed work is a one-year process evaluation and two-year impact evaluation of a produce prescription program (FLiPRx). The goals of the FLiPRx program are to encourage fruit and vegetable intake in historically low-produce consumers experiencing food insecurity and are at-risk of nutrition-related chronic disease and to evaluate the impact of the program on health outcomes and healthcare utilization and cost. The expected outcomes are (1) improved dietary health through increased consumption of fruits and vegetables; (2) reduction of individual and household food insecurity; (3) improved health outcomes; and (4) reduction in healthcare use and healthcare associated costs. We will achieve this goal by conducting a prospective cohort study. We will deliver the 6-month FLiPRx produce prescription program to 150 total eligible families over the course of 3 years and conduct assessments to evaluate the delivery and implementation process (year 1) and the impact (years 2-3) of the program. Over the course of the 6-month FLiPRx program participants will receive bi-weekly (every other week) deliveries of 8 pounds of fresh produce delivered to their home and approximately 12 hours of family-centered, culturally relevant nutrition education in the form of video messaging (FLiP Tip Videos), written instructional guides (print material and a website), an "onboarding kit" with basic kitchen supplies, and six monthly live learning sessions. Participants will complete pre- and post-intervention surveys and qualitative interviews assessing food security, fruit and vegetable intake, home environment and cooking practices, and nutrition and culinary knowledge and self-efficacy. We will also conduct prospective and retrospective chart reviews and review utilization and claims data to explore the impact of the program on health outcomes, healthcare utilization, and cost.Year 1 Goals: To conduct a process evaluation to assess the feasibility and acceptability of the FLiPRx program and to identify areas for improvement and re-design based on key stakeholder feedback. Year 1 Objectives: We will conduct an initial pilot study to quantitatively and qualitatively assess feasibility and acceptability of the FLiPRx program and the evaluation plan. We will deliver the FLiPRx program to 50 families and monitor recruitment, retention, participation, and acceptance of the FLiPRx program and data collection tools. We will track program enrollment, participant attendance (at live learning sessions) and viewership (FLiP Tip videos), and pre-post and monthly survey completion rates. We will also conduct monthly key informant interviews with the Program Assistant and participants to identify barriers to participation and engagement. We will conduct post-intervention qualitative interviews with participants to understand their thoughts and feelings about the overall program curriculum, delivery, and design.Years 2 and 3 Goals: We will conduct an impact evaluation to measure the immediate and potential long-term effects of the FLiPRx program protocol on diet change (eating fruits and vegetables), food security, clinical metrics of health, and to explore healthcare utilization and cost outcomes. Years 2 and 3 Objectives: We will deliver the FLiPRx program protocol to 100 families and evaluate the effect of the program on changes in 1. diet, 2. food security, 3. health outcomes, and 4. healthcare utilization and cost by conducting a quasi-experimental prospective cohort study with a pre-post- quantitative and post-intervention qualitative evaluation plan. Objective 1: Characterize the longitudinal change in diet quality with an emphasis on fruit and vegetable consumption in 100 child and adult caretaker dyads (total n=200) using Diet Screen Questionnaire (DSQ), and a 24-hour recall (in a random sub-sample of n=50; 25 children and 25 adults). Objective 2: Characterize the longitudinal change in household food security in n=100 9 families (adult reported), using the USDA food security supplement questionnaire. Objective 3: Characterize the longitudinal change in health outcomes in n=100 children by conducting a retrospective and prospective chart review to assess clinical labs, vital signs, and growth parameters. Exploratory Objective 4: Explore the longitudinal change in healthcare utilization and health care costs in n=100 children by assessing clinical care and claims data. Ancillary objectives: We will assess demographic (education, income, gender, race), household environment, culinary and nutrition knowledge, self-efficacy, and program participation factors (engagement, utilization, uptake, knowledge) in n=100 adults to control and explore the interactions between these factors and the effectiveness of the intervention on the primary objectives listed above.
Project Methods
Study Design - Year 1 is designated for a process evaluation, utilizing an iterative quality improvement plan to result in a defined protocol to be implemented in years 2 and 3. Years 2-3 are designated for impact evaluation, to evaluate the effect of the FLiPRx program protocol on objectives 1-4. To achieve the process and impact objectives listed above, we will conduct a mixed-methods longitudinal cohort study with a behavioral intervention (FLiPRx), including pre- and post-intervention quantitative and qualitative evaluations. Delivery Of the FLiPRx Program - Over the 3-year grant period, we will screen 600 referred families and enroll 150 eligible families into the FLiPRx program. Referred families receive a one-time produce delivery, a brief nutrition education (FLiP Tip video), increased access to 10 national and local supplemental food programs, and are screened for eligibility. Eligible families enrolled into the program will receive six months of fresh produce, nutrition education, and increased access to national and local supplemental food programs with the goal of increasing food security and improving healthy eating behaviors in families at risk of nutrition-related disease. In Year 1, program participants will receive 8 pounds of fresh fruits and vegetables, delivered to participants' homes on a bi-weekly basis (every other week) for 28 weeks, and approximately 12 hours of nutrition education via bi-weekly online video messaging (FLiP Tip videos), a print produce resource guide and website, and monthly online live learning sessions demonstrating food preparation by a chef and behavior change support from a registered dietitian and peer educator. During Year 1, our quality improvement process (plan-do-check-act, PDCA) may identify opportunities for improvements to this delivery or curriculum plan, such as changing delivery frequency or allowing for greater individualization of fruit and vegetable choices (we will not change the basic framework of produce delivery and nutrition education). We will evaluate monthly quantitative and qualitative data ("check") to identify barriers and facilitators to participation and satisfaction. We will meet as a team with our community advisory board to determine what actions need to be taken, based on what we learned ("act"). We will plan new improvements to be implemented ("plan") and incorporate said change into the FLiPRx program ("do"). We will begin the cycle again with monthly data evaluation (check-actplan-do). At the end of Year 1 we will define a FLiPRx program protocol that will be implemented and tested in a cohort study in Years 2 and 3, without significant changes to the protocol. Participant selection/enrollment - Over the 3-year grant period, we anticipate enrolling 150 eligible CNH clinic patients and one of their adult caretakers (total n=300). Participants will be recruited from outpatient CNH clinics in Ward 7 and 8. During clinic visits, adults who present with children aged 0-18 years old will be screened by clinicians for FI with a 2-question screener (Hunger Vital Sign, HVS)[29]. Adults who screen positive and their child present for the clinic visit (reference child) will be referred to the FLiPRx program by their clinician. The research team will contact referred families by phone to confirm nutrition-related disease risk eligibility criteria (self-report presence of rapid weight gain, overweight, obesity, hypertension, non-alcohol fatty liver disease, hypercholesterolemia, or prediabetes, diabetes in adult or child), and additional eligibility criteria defined as one of the following: (1) eligible for benefits under the 11 Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.); or (2) enrolled in medical assistance under a state plan or a waiver of such a plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). If deemed eligible, the research team member will explain the study and obtain informed consent, as defined in our existing IRB protocol. We anticipate collecting data from 150 children and 150 adult caretakers for this process and impact evaluation. This sample size was determined based on feasibility of recruitment and assuming 20% attrition due to drop out from the program or lost to follow ups. Procedures - Pediatric clinicians will refer patient families to FLiPRx through our existing REDCap [30] database. The study team will contact families to screen for eligibility, describe the study, and obtain informed consent by phone as per our existing IRB protocol. In Year 1, after providing their informed consent, 50 eligible families will be enrolled into our 6-month produce prescription and nutrition education intervention. We will conduct monthly satisfaction surveys and pre- and post-intervention surveys online via REDCap. After the 6-month program, we will conduct qualitative interviews to understand participant's thoughts and feelings about the program and identify any areas for program improvements. We will also conduct monthly key informant interviews with the community liaison and participants to understand barriers and facilitators to program participation and engagement. We will meet with the community advisory board (at minimum on a quarterly basis) to review our findings and conduct quality improvement activities as described above. In Years 2 and 3, 100 eligible families will be enrolled into the FLiPRx program protocol (produce delivery and nutrition education). We will conduct monthly satisfaction surveys and pre- and post-intervention surveys online via REDCap. After the 6- month program we will conduct qualitative interviews to understand the participant's thoughts and feelings about the program and contextualize the quantitative findings. We will conduct retrospective and prospective chart review to collect child clinical data and will work with clinic administrators to collect child utilization and claims data for the year before participation in the study and up to 1 year after participation in the study.