Non Technical Summary
Boulder County Public Health (BCPH) will be partnering with Adams County Health Department (ACHD) and Clinica Family Health to enroll at least 200 pregnant patients into a Produce Prescription Program (PPR). Patients will be enrolled within the first 30 days after initiating prenatal care until at least 3 months after their child is born. Any pregnant patient receiving care at the Lafayette or Thornton Clinica Family Health site who is enrolled in Medicaid and is either 1) a person of color and/or Hispanic/Latina, 2) food insecure, or 3) has a diet-related disease will be eligible to enroll into the PPR. Program participants will receive nutrition education, along with a medically tailored produce delivery, valued at $50 per produce box, to be delivered every other weekResearch that indicates that people of color (POC) and people who are food insecure have a higher risk of developing a diet-related disease. Furthermore, food insecurity is significantly associated with type 2 diabetes and it is linked to high blood pressure and high cholesterol. POC are up to two times more likely than whites to have most of the major chronic diseases. POC face higher rates of diabetes, obesity, stroke heart disease and cancer than whites. The risk of being diagnosed with diabetes is 77% higher for African Americans and 66% higher among Hispanics, than for non-Hispanic whites. Based on Clinica's patient demographics, it is anticipated that at least 75% of patients served by this PPR will identify as Hispanic/Latino.Research shows that adequate nutrition during pregnancy is crucial for fetal development, perinatal outcomes and birth outcomes. Nutritional inadequacies during pregnancy can affect a child's growth and may predispose them to chronic illness, obesity, diabetes, cardiovascular disease and poor cognitive development. Additionally, fruit/vegetable consumption during pregnancy has been associated with a lower risk of developmental delays such as speech and language development, motor development, social-emotional development and cognitive development in infants and toddlers. With this grant we aim to increase fruit and vegetable consumption while decreasing food insecurity for pregnant people receiving care at Clinica Family Health.Patient advisory boards will be developed during the planning phase of this grant to help inform program design. The patient advisory board will meet on an on-going basis to help co-design educational components of the PPR and contents of the produce boxes, and to give continual feedback throughout the pilot project.Patients enrolled in the PPR will take a baseline and a follow-up survey to measure changes in fruit and vegetable consumption, and food insecurity. Clinical outcomes such as 1) the number of preterm births 2) the number of term births 3) the number of no-shows for appointments and 4) birthweights will be measured for pregnant patients enrolled in the PPR versus pregnant patients who were not enrolled in the PPR.

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
704	6099	1010	100%

Knowledge Area
704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
1010 - Nutrition and metabolism;

Goals / Objectives
The goals of this produce prescription program are to: increase fruit and vegetable consumption, decrease food insecurity, and improve prenatal health and birth outcomes in pregnant patients. Approximately 200 pregnant patients will be enrolled in the PPR program and will receive a medically tailored box with a range of fresh fruits/ vegetables delivered every other week from the time of enrollment through the fourth trimester. By receiving nutritional education and produce deliveries, it is anticipated that this PPR will see similar results to other national PPR programs including:Objective 1: PPR participants' food insecurity decreased by approximately 17 percent Objective 2: PPR participants will increase their daily fruit/vegetable intakeObjective 3: PPR participants will see a decrease in no-show visits, preterm deliveries and low birth weights.

Project Methods
Prescribed produce boxes will be delivered every other week by a produce box vendor to pregnant people enrolled in the PPR. Clinica providers will identify pregnant patients during prenatal visits to ensure Medicaid status and that they meet at least one of the three eligibility criteria. Boxes can be medically tailored for specific health conditions and to support prenatal nutritional needs. Patients will be enrolled into the program within 30 days after their first prenatal visit and they will remain in the program until at least three months after giving birth. Produce box contents will be informed by nutritional research to incorporate an evidence-based design to ensure optimal effectiveness of this PPR.All 200 patients who enroll in the PPR will be required to take a baseline survey to begin receiving produce boxes. BCPH anticipates a budget for client stipends of $20 to encourage participants to take a follow-up survey which will measure changes in fruit and vegetable consumption, and food insecurity. The baseline survey will include the NTAE core metrics including the 10-item fruit and vegetable diet screener, the USDA 6-item short form food security screener, questions about enrollment in SNAP or WIC, health status, socio-demographics, geography, and how the survey was taken. Follow-up surveys will be administered after the two month newborn visit. Follow up surveys will solicit feedback about the produce boxes, what percent of the produce box was utilized and which aspects of nutrition education the patient accessed, in addition to the diet screener and food insecurity screener included in the baseline survey.Mid program feedback will be solicited from PPR participants via key informant interviews or standardized surveys. Participant feedback will be used to gauge quality of produce boxes and for implementing programmatic changes as needed.In order to evaluate firm level metrics, including clinical outcomes for patients enrolled in the PPR, Clinica will gather data and build a corresponding report for: 1) the number of preterm births 2) the number of term births 3) the number of no-shows for appointments and 4) birthweights. These data points will be pulled during the last quarter of the grant for pregnant patients receiving care at a Clinica site. Results from patients enrolled in the PPR will be compared to pregnant patients who were not enrolled in the PPR. Data will be analyzed to determine whether the number of preterm births decreases, no-shows visits decrease and low-birth weight births decrease when patients are enrolled in the PPR. BCPH will work with Clinica to determine if the results are clinically significant.BCPH will monitor and track all produce deliveries. Monthly reporting from the produce box vendor will start after the initial planning period once patients have been enrolled into the PPR program. Monthly reports will include information about:the number and type of produce boxes delivered, dollar amount of produce delivered, the number of patients actively enrolled in the program, the number of educational opportunities that were offered, the number of patients who drop out of the program and the number of patients who complete the program (i.e. are past the fourth trimester), and any additional participant feedback.