Project Overview: Deeply entrenched poverty, limited transportation options, and vast food deserts pose considerable health risks to many communities in Idaho, contributing to and exacerbating diabetes and other medical conditions. In an effort to address the problem, Idaho Primary Care Association (IPCA) worked with community partners to launch a Fruit and Vegetable Prescription Program (FVRx), an evidence-based program that promotes access to healthful, nutritious food through partnerships between healthcare providers, local food suppliers and community members. The program initially targeted patients with uncontrolled diabetes and other co-morbidities and their family members. In Year One, the program was implemented at the Terry Reilly Health Services (TRHS) site serving Nampa’s 1st and 16th street neighborhoods, where the proportion of patients with poor diabetes control is far in excess of the statewide average, and many people reported poor or fair health. In year two, IPCA supported the continuation of the FVRx program at TRHS, while extending the project to Valley Family Health Care (VFHC) in Payette and Ontario, ID.
The goal of the project was to improve health outcomes for high-risk patients with diabetes and other chronic conditions by improving access to healthful and nutritious foods.
Project objectives in year one were to:
- Improve patient health by allowing providers to prescribe fruits and vegetables as part of a nutritious diet;
- Empower patients to adopt new eating patterns and develop cooking skills required to create lasting lifestyle changes; and
- Benefit local retailers and farmers by increasing demand for fruits and vegetables to sustain access to wholesome and nutritious food.
2018-2019 Project Outcomes:
- Enrolled a total of 174 patients in the three 12-week sessions;
- Of the 174 enrolled patients, 108 (62%) received nutrition education from a dietician through either a one-on-one session or group appointment, or during a cooking class, qualifying them to receive free produce at the weekly produce market;
- Eighty-five (85) of the 108 eligible patients (78.7%) attended the weekly produce market at least four times over the course of the program to acquire free produce;
- This group of 85 patients ( who both attended a RDN individual or group appointment or cooking class, and visited the produce market at least four times over the course of the program), attained an average reduction in HbA1c of 1.6%; 38 patients in the group (44.7%) reduced their BMI; and
- Through partnership with the Boise Mobile Farmers Market, provided access to fresh fruits and vegetables for participants in the first program session. The program was beneficial to the market as well as to the participants: the partnership increased produce sales at the Boise Mobile Farmers Market mobile market by 27.8%, including approximately $5,527 paid to local farmers, and approximately $1,843 to help support the Mobile Market.
In the second year of program operations, and with the addition of second project site, the program focused on enrolling high-risk diabetic patients in the comprehensive FVRx program, attaining a high degree of participation in the program’s registered dietitian nutritionist (RDN) support and voucher redemption components, achieving measurable HbA1C reductions among the program participants, and improving food security.
2019-2020 Project Outcomes:
- In total, the FVRx program engaged 333 health center patients over the course of two years, in two CHC organizations;
- In year two, TRHS enrolled 105 patients, exceeding its enrollment target of 100 patients. Sixty-two (59.0%) of those enrolled completed the program. These patients attended at least four appointments (from among one-on-one or group appointments with the registered dietician nutritionist, Cooking Matters course, or pharmacist visit) and redeemed FVRx vouchers;
- Of those patients who completed the program and returned for a retest of their HbA1c (n=48), 70.8 % (34) saw a decrease in their HbA1c of 0.5% or greater by the end of the program. Among TRHS patients who participated in year 2 and measured their BMI at the conclusion of their enrollment (n=101), 34.7% (35) decreased their BMI. The average reduction among this population was -0.30 kg/m2;
- Joining in year 2, VFHC nearly achieved its enrollment target and enrolled 57 patients, in two cohorts. Among patients in the first cohort of 31 patients, 26 (80.6%) participated in Cooking Matters classes and more than half (51.6%) met with a behavioral health specialist. Twenty-six patients were enrolled in the second cohort; COVID-19 stay-at-home orders led to the cancellation of the Cooking Matters classes for the second cohort and some modifications to the program;
- For all VFHC patients who completed the program and returned for a retest (n=46), 61% saw a decrease in their HbA1c. Among VFHC patients who participated and measured their BMI at the end of their program enrollment (n=51), 49.0% (n=25) decreased their BMI. The average reduction among this population was -.10 kg/m2;
- To measure food security, pre-and post-surveys were conducted of participants at both health centers, evidence a high degree of food insecurity. (TRHS, 59.6%, VFHC, 53.1%). While some patients indicated that they did increase their consumption of fruits and or vegetables, overall, no patients reported feeling more food secure as a result of the program; and
- Independent evaluators from the Idaho Center for Health Research at Idaho State University assessed program efficacy utilizing both process evaluation and outcomes evaluation approaches incorporating statistical analysis of health metrics and self-reported outcomes. The objective of the evaluation was to determine the potential relationship between program participation and favorable change in HbA1C and BMI, as well as whether other program elements such as the monetary value of vouchers were significant predictors of outcome.
- At TRHS, program completers in both years 1 and 2 experienced statistically significant favorable differences in HbA1C. In year one, BMI changes were not significant for participants. In year two, BMI changes were significant for the whole cohort, but not for the participants who completed the program. Program participation was not found to be predictive of changes in HbA1C or BMI.
- At VFHC, changes in HbA1C were similar for both program completers and non-completers in cohort 1; since most participants (80.6%) were completers, the sample size of the non-completers was likely too small to be meaningful. Although the program was modified due to the COVID-19, limiting the scope of the intervention, HbA1C differences for the second cohort were also significant for all the participants; here differentiation between completers and non-completers was not possible due to the limited dataset. For cohort 1, participation in the Cooking Matters classes was significant with regard to reductions in HbA1C, while voucher redemption, and group medical appointments plus behavioral health were significant with regard to reductions in BMI.
- The value of vouchers was not a significant predictor of change of HbA1C or BMI, nor was the monetary value of the vouchers redeemed a significant predictor of post-intervention HbA1C or BMI for participants at either health center.
Project Partners: InvestHealth Nampa, Boise Mobile Farmer’s Market, Saint Luke’s Health System, St. Alphonsus Regional Medical Center, Idaho Healthcare Coalition, HealthComm Solutions, Idaho Food Bank, Idaho Hunger Task Force, Terry Reilly Health Services, Valley Family Health Care.
About the Grantee
The Idaho Primary Care Association (IPCA) has been the leading state advocate for community-based health care programs since 1983. The association plays a vital role in educating federal, state and local policy makers about issues relating to health care and the role of community health centers. The IPCA also provides training and technical assistance to Idaho’s community health centers in the areas of community development, quality improvement, workforce development and health center operations. For more information, visit www.idahopca.org.