Engaging Latina Females and Community Partners to Pilot Test and Optimize Medically Supportive Groceries

Abstract

Background

Food insecurity and diet-related chronic disease disproportionately affect Latina females. Food is medicine (FIM) is increasingly recognized for its role in addressing the dual challenge of food insecurity and diet-related chronic diseases. However, there is minimal evidence to guide FIM practice for Latina females.

Objectives

This study aims to engage Latina females and community partners to test the acceptability, implementation feasibility, and preliminary effectiveness of medically supportive groceries.

Methods

In partnership with a Federally Qualified Health Center and community partners, Latina females at risk of diet-related chronic disease who screened positive for food insecurity (n = 25) received 8 weekly home deliveries of medically supportive groceries. Participants completed semistructured interviews, as well as surveys, at baseline and 8-wk follow-up. Interview transcripts were coded using inductive thematic analysis. Changes in food security and dietary intake were assessed using a pair sample t-test and McNemar’s χ² test.

Results

Females had a mean age of 52 y (34–73 y old), with 84% indicating a household income below the federal poverty line, and 77% had children at home. Participants were recruited within 4 wk and achieved a 100% success rate in delivering food. Interview themes included cultural acceptability and satisfaction, individual and household benefits of participation, facilitators for optimal use, and barriers. At follow-up, 59% reported food insecurity compared with 92% at baseline (P = 0.016). Participants reported comparable levels of daily fruit and vegetable intake at baseline and follow-up (P = 0.7).

Conclusions

Findings demonstrated that medically supportive groceries are feasible and acceptable for Latina females with diet-related chronic diseases and support comprehensive FIM interventions in diverse populations.

Introduction

Food insecurity—the lack of consistent access to sufficient quantities of healthy food—affected 18 million households in the United States in 2023, which was a significant increase from prior years [1]. The expiration of pandemic-related social supports, coupled with high food costs, is likely to blame for this increase. Minoritized groups, like the Latinx immigrant community, are more likely to be affected by household food insecurity compared with non-Latinx households. The most recent national data found that 22% of Latinx households were classified as food insecurity compared with 10% of non-Latinx white households [2]. Furthermore, 7% of Latinx households were classified as very low food insecurity compared with 4% of non-Latinx white households, indicating higher reductions in food intake and disrupted eating patterns due to lack of resources [2]. Food insecurity is emerging as a public health concern and a modifiable risk factor for diet-related chronic diseases, such as diabetes and cardiovascular disease, that disproportionately impact the Latinx community as well [[3], [4], [5], [6]].

Within the Latinx community, Latina females are particularly impacted by food insecurity and diet-related chronic diseases. Latina females are particularly susceptible to weight gain and obesity as a result of food insecurity [3,[6], [7], [8]]. This may be due to reliance on low-cost energy-dense foods, particularly in favor of preserving high-cost foods for other family members. The dual challenges of food insecurity and diet-related chronic diseases may be compounded for Latina immigrants who have yet to establish and/or access the resources needed to cope with food insecurity.

Food is Medicine (FIM) is increasingly recognized for addressing the concurrent challenges of food insecurity and diet-related chronic diseases, including by the 2022 White House Conference on Hunger and Nutrition [9]. FIM is an umbrella term for nutrition programs in conjunction with behavioral interventions that are implemented in the healthcare setting. Medically supportive groceries are 1 form of FIM that entails providing patients with foods that can support the prevention or management of specific diet-related chronic diseases, like diabetes, that may respond to dietary and lifestyle modifications [10]. There has been a proliferation of FIM programming, as well as research efforts, to evaluate these programs [11]. However, there is limited evidence to inform the implementation of medically supportive groceries, especially among Latina females.

Therefore, the goal of this study was to pilot test medically supportive groceries for Latina females with food insecurity and 1 or more diet-related chronic disease(s), including obesity. The resulting medically supportive grocery program will be combined with an existing evidence-based behavioral lifestyle intervention known as Vida Sana in a future large-scale trial [12,13]. Together with healthcare and community partners, we evaluated the acceptability, implementation feasibility, and preliminary effectiveness of medically supportive groceries within a primary care setting. This will add to existing literature on the development of FIM for Latina females, contributing critical insight into the importance of culturally inclusive adaptations for community-engaged research [14].

Methods

Setting, partners, and participants

The study was based in North Fair Oaks, a community in the San Francisco Bay Area with a large percentage of immigrants (42%) and Latinx community members (72%) [15]. To facilitate the codesign process, we engaged 2 community health centers, including a Federally Qualified Health Center (FQHC) and a community-based organization (CBO) that provides free healthcare and has a food pantry, the local food bank, Second Harvest of Silicon Valley, and Peninsula Food Runners, a volunteer-based organization that delivers prepared and nonprepared food to community members and organizations. Via weekly planning meetings, the partners collaborated to design the intervention, monitor implementation, and strategize the dissemination of findings to inform a medically supportive grocery program. The FQHC was responsible for referring eligible females to the program. The CBO with the free clinic and food pantry was responsible for referring eligible females and assembling grocery boxes with foods provided from the food bank. The food bank provided food to the CBO and Peninsula Food Runners delivered the groceries to the participants. The planning meetings included discussions such as ensuring that the grocery boxes only contained healthy food items, planning for efficient pick-up and delivery methods that were appropriate for each organization’s workflow, and ensuring accurate and timely communication between implementation partners and participants. During the project implementation, we engaged in weekly communication with all partners via email and phone to keep partners updated on progress and in the event of any logistical issues that emerged. The study was approved by the Stanford Medicine Institutional Review Board (Protocol #58557). Self-identified Latina females with a BMI (in kg/m²) of 30 or greater, and who screened positive for food insecurity using the Hunger Vita Sign [16], were referred by their primary care providers or other clinic staff (e.g., nurses, dietitian) at 1 of the partner clinics.

Pilot intervention description

Participants received 8 weekly doorstep deliveries of medically supportive groceries. The food bank delivered the groceries to the food pantry on a weekly basis where volunteers prepared and delivered the groceries. Groceries were ∼12 pounds and included 50% of produce (e.g., fresh fruits and vegetables), 25% of protein (e.g., low-fat milk, fresh poultry, eggs, whole beans, and yogurt), and 25% of whole-grain items (e.g., corn tortillas, whole wheat bread, brown rice, and oatmeal). Eight weeks was chosen to examine acceptability among participants, implementation feasibility, and preliminary effectiveness of medically supportive groceries in this population. Nutrition education was intentionally not provided, as this pilot study was designed to test the grocery box component of a FIM intervention. Our team has previously tested and culturally adapted nutrition education and lifestyle interventions within the Latinx community as the other key component of FIM [13,17,18].

Measures

Qualitative

To examine acceptability and feasibility, participants completed 2 30-min qualitative interviews over the phone, 1 at 4 wk and 1 exit interview at 8 wk assessing participants’ current use of items in the medically supportive grocery box, food preparation routines in the house, facilitators and barriers to making optimal use of the provided foods, cultural acceptability of the included items, acceptability of the delivery experience, and feasibility via implementation logistics and practicality. Moreover, the exit interview inquired about interest in similar programs, including both food and behavioral lifestyle interventions. Other feasibility measures included the percent of grocery boxes delivered and the timeline for participant recruitment.

Quantitative

To examine preliminary effectiveness, participants completed 2 brief telephone surveys at baseline and at 8 wk. Surveys consisted of: 1) demographics; 2) 10-item Dietary Screener Questionnaire (DSQ-10) assessing nutrition during the past month [19,20]; 3) USDA 6-item food insecurity questionnaire [21]; and 4) questions about the use of other resources for food assistance including Supplemental Nutrition Assistance Program, Women, Infants and Children, and others. Baseline measures also included self-reported medical conditions (e.g., diabetes, heart disease, hypertension, cancer, etc.). DSQ-10 frequency responses were converted to daily frequency using standard procedures [22]. All measures were available in English and Spanish. Participants received $5 store gift card after completing each of the surveys, and $10 after completing each interview for a total of $30.

Data analysis

Qualitative

Acceptability and feasibility were assessed with standard qualitative analysis. For qualitative data, interview audio recordings were transcribed verbatim and grouped by time (i.e., 4-wk and 8-wk follow-up). Transcripts were coded independently by 2 researchers using inductive thematic analysis. The research team reviewed 5 transcripts to a codebook before coding began; afterward, codes were categorized into 4 major themes outlined in the results. During the coding process, weekly meetings between the 2 coders and a senior qualitative researcher were used to discuss discrepancies, clarify and continue to refine codes, and for consensus building. Qualitative data were analyzed using NVivo.

Quantitative

Changes in self-reported food security and dietary practices at baseline and 8-wk after the start of the grocery delivery were assessed using a pair sample t-test and McNemar’s χ² test. Quantitative data were analyzed using SAS Enterprise Version 13 [23].

Results

Females had a mean age of 52 y (range: 34–73 y old), were primarily foreign born (92%), with incomes below the federal poverty line (84%), and 77% had children at home (Table 1). Common self-reported medical conditions included prediabetes or diabetes (84%), high cholesterol (52%), hypertension (40%), depression (32%), some form of arthritis (24%), and asthma (12%). All participants reported overseeing grocery shopping and preparing food for the household.

TABLE 1.

Participant and community demographic information.

	Total sample (n = 25)
Participant demographics
Age (SD), y	52 (10.3)
BMI (SD), kg/m2	35.02 (6.44)
Gender (% female)	100
Hispanic/Latina (%)	100
Foreign born (%)	92
Average years in the United States (SD)	17 (6)
Marital status (%)
Married or living with partner	52
Partnered, not living together	8
Separated	16
Widowed	20
Single	4
Education1 (%)
High school or less	84
Associates degree	4
Some college	8
College	4
Yearly household income (%)
≤14,999	44
15–25 K	40
25,001–50 K	12
>50 K	4
Average number of individuals supported by income (SD)	3.6 (1.7)
Children in household (%)	77
WIC users (%)	4
SNAP users (%)	16

Abbreviations: SNAP, Supplemental Nutrition Assistance Program; WIC, Women, Infants, and Children Program.

¹Eighty-four percent of participants indicated completing education outside of the United States.

Qualitative findings

Four themes emerged from the qualitative interviews: 1) cultural acceptability and satisfaction, 2) individual and household benefits of participation, 3) facilitators for optimal use, and 4) barriers (Table 2). Collectively, these 4 themes informed multiple recommendations and considerations for implementing FIM interventions among Latina females.

TABLE 2.

Qualitative themes and illustrative quotes.

Theme and subtheme	Definition	Illustrative quote
Cultural acceptability and satisfaction
Integrating and substituting food items	Replacing typical products used in the home with items in the grocery box and adding products in the grocery box to daily diets.	“I barely ate oatmeal and now I found a way to make it. In the morning, I cook it with water, slice an apple on top drizzle a little bit of honey, and eat it for breakfast.” [2.28]
Staple food items	Inclusion of fundamental culturally relevant food (e.g., rice, bread, beans, etc.)	“I liked that it had cheese for quesadillas.” [1.06]
Desire to continue participation	Expressing wish to continue receiving grocery boxes beyond 8 wk	“Of course, yes, I would definitely like to continue.” [2.02]
Recommend to others	Desire to let others know about the grocery box delivery program—as indicator of satisfaction.	“Yes I would recommend it, because honestly nobody brings a food box to your doorstep. It is really good, and I am very thankful.” [2.06]
Individual and household benefits of participation
Financial savings	Expressing financial relief from receiving grocery boxes and now being able to use money for other basic needs	“I have not done the exact math of all that we get in the box, but receiving this basic nutrition, gives us the opportunity to buy other necessary things – medicines, clothes, shoes.” [2.15]
Expanded food selection	Describing items in the grocery boxes as generally too expensive at stores therefore individuals do not purchase at all or purchase very little	“I used to buy a little bit, just a cup and not always, because oatmeal is very expensive.” [1.01]
Self-perceived health impact	Reflecting on perceived health impacts of utilizing the food boxes (e.g., weight loss, lower blood sugar levels, etc.)	“For people who have diabetes or high cholesterol, like me, and are overweight; this has helped a lot.” [2.14]
Facilitators for optimal use
Doorstep delivery	Comments about the delivery including convenience, barriers to acquire grocery boxes otherwise, etc.	“Since I am older […] I cannot carry things very well. But I thank you for bringing this here, to my doorstep.” [2.18]
Quantity	Describes the overall satisfaction with the amount of food in the boxes	“It is enough to make 3 meals, I think it is good.” [1.01]
Quality	Describes the overall satisfaction with the freshness and food grade of the items in the boxes	“The vegetables are fresh, the carrots are very fresh, and the pineapple is very good. Everything is very good.” [1.09]
Barriers
Less desired items	Describing food items that are not new to the family but rather are less desired or utilized.	“We do not use [eat] grapefruit.” [1.07]
Difficulty integrating novel food items	General sentiment of lack of familiarity with specific food items	“I am not used to eating whole grain pasta, but we are eating it now.” [1.14]
Shelf life	Preference for items that stay fresh and can be stored for longer periods of time.	“Sometimes the milk arrived and would expire the next day… It only bothers me that it doesn’t last for more days.” [2.12]

Theme 1: cultural acceptability and satisfaction

In over 90% of interviews, participants discussed aspects of cultural acceptability and satisfaction, including integrating unfamiliar food items into diet, substituting unhealthy food items for healthier alternatives, staple food items, expressing a desire to continue receiving the grocery boxes, and willingness to recommend the program to others. Participants noted that the inclusion of familiar staple food items (e.g., rice, beans, eggs, etc.) was critical in enhancing the cultural acceptability of the grocery boxes and in allowing them to make full meals their families were familiar with. Moreover, including staple food items in medically supportive groceries often facilitated the integration of novel food items (e.g., dairy free milk, oatmeal, squash, and lentils) as participants could mix items in staple dishes (e.g., stew, quesadillas, pastas, salsa, etc.). All participants expressed overall satisfaction with the grocery boxes, including with the quantity and quality. All participants (100%) expressed a desire for continued participation in the grocery box delivery program and mentioned they would recommend the program to others.

Theme 2: individual and household benefits of participation

Several factors, including financial savings, being able to access more expensive food items, and self-perceived health changes, were identified as benefits of enrolling and using the grocery boxes. Participants expressed that grocery boxes positively impacted household finances as it allowed them to utilize their food budget to pay for bills or purchase other necessary household items. Many participants shared that healthy food items (e.g., lean proteins) included in the grocery boxes were otherwise too expensive to purchase at the store, therefore, making the boxes an opportunity to access items that may have not previously been financially accessible. In reflecting on the benefits of using boxes, approximately one-quarter of participants shared, unprompted, that they perceived beneficial health impacts (e.g., weight loss, lower blood sugar levels, reduced stress, or worry regarding food security).

Theme 3: facilitators for optimal use

Doorstep delivery, quantity, and quality of food items were identified as facilitators to utilizing the food provided in the boxes. When participants were asked what worked well with the implementation of the grocery boxes, many noted doorstep deliveries as a major facilitator, as it eliminated transportation barriers (e.g., driving, finding a ride, walking long distances, etc.). Of note, a majority of participants (65%) did not drive or have access to a personal vehicle. Therefore, without doorstep delivery, participants would have needed to rely on external support (e.g., friends, other family members) for assistance with picking up the grocery boxes. Most also had children and expressed additional time and logistical constraints (e.g., having to walk back with a heavy box and small children) that limit their ability to pick-up, even if the place is relatively close by. Additionally, participants shared that the overall quantity of the grocery boxes was sufficient for multiple meals for their families, and the overall quality of food items was described favorably, which allowed them to fully utilize the items.

Theme 4: barriers

Three factors were identified as barriers to optimally using the grocery boxes including less desired items, difficulty integrating novel food items, and spoiled foods. Approximately half of the participants shared that there were food items that while familiar, families did not want to consume (e.g., grapefruit, brown rice, canned beans) that were not utilized in the home prior to the grocery boxes and were harder to integrate into daily meals and food preparation. Although participants noted they were not reluctant to try novel food items, they emphasized unfamiliarity as a barrier to consuming some items (e.g., whole-grain pasta, brown rice, squash), as it was challenging to integrate them into familiar meals. Participants also shared that, at times, items were near expiration or in unfavorable conditions, particularly produce, making it challenging to consume in time or at all.

Recommendations derived from qualitative themes

Participants discussed considerations to make when creating similar medically supportive grocery programs for Latina females, including recipes, mode of delivery, and inclusion of additional produce. To encourage greater use of items in the boxes, nearly all participants expressed a need for culturally tailored recipes, and in their preferred language, to facilitate the integration of novel food items. When prompted about foreseeable challenges with programs not offering doorstep delivery many participants noted transportation access, lifestyle limitations (e.g., caregiving demands), and chronic health conditions would make grocery boxes inaccessible to them if not delivered.

Quantitative findings

Feasibility measures

We were able to recruit 25 participants within 4 wk of launch and the project team achieved a 100% success rate of delivering food to participants.

Preliminary effectiveness

Approximately 92% of females reported food insecurity at baseline (n = 25) with 52% reporting very low food security. At follow-up, 59% (n = 22) reported food insecurity and 14% of them reported very low food security (Figure 1). This represented a significant decrease in food insecurity (92% compared with 59%, P = 0.016). Half (n = 11) of the females reported an improvement in food security, defined as moving categories (e.g., from “very low food security” to “low food security” or to “food secure”). Participants reported comparable levels of daily fruit and vegetable intake at baseline (mean = 2.8 daily cups, SD = 1.2) and at 8 wk (mean = 2.9, SD = 1.1; mean difference 0.08, P = 0.7), with one cup equivalent to 2 servings.

FIGURE 1.

Food security classification before and after the grocery box intervention. Note. Before, n = 25; after, n = 22. Food secure/marginal = 0–1 scores on USDA 6-item measure; low food security = 2–4 score; very low food security = 5–6 score.

Partner discussion

Healthcare and community partners reviewed both the qualitative and quantitative findings as a group and discussed how the participant’s experiences in the pilot grocery box program could inform a comprehensive FIM program that includes medically supportive groceries and a behavioral lifestyle intervention. Ultimately, the partners concluded that a medically supportive grocery program was both feasible to implement and well-accepted among Latina females. The findings highlighted the importance of doorstep delivery for this population and integration with a culturally tailored behavioral lifestyle intervention that provides health education and support for incorporating new foods. Partners noted that an 8-wk duration was too short and that future programs should be a minimum of 12 wk to align with state FIM policies.

Discussion

This pilot study provided information about important factors to consider when implementing medically supportive groceries as part of comprehensive FIM programs for Latina females. The pilot study revealed that medically supportive groceries were culturally acceptable and feasible as indicated by qualitative and quantitative findings and input from implementation partners. The qualitative interviews underscored the need for nutrition education to further support incorporating new foods into their meals and the role of doorstep delivery in addressing transportation and other logistical barriers to participation. The survey data showed significant improvements in food security status, but no significant changes were observed in fruit and vegetable consumption.

There is limited research on the acceptability and feasibility of medically supportive groceries for Latina females, particularly when the food is provided by a charitable food network, such as a local food bank or food pantry. A recent study explored multiple configurations of grocery boxes in alignment with the dietary approaches to stopping hypertension diet among Latinx households in FIM interventions [24]. Although the participants in this pilot intervention did not explicitly have a cardiovascular disease diagnosis, similar responses were observed among Latinx participants, such that cultural tailoring with familiar foods and challenges preparing novel foods were barriers to participation [24]. Others have also evaluated cultural and disease-specific nutrition resources to improve FIM in an outpatient primary care center on-site food pantry [25]. Multicultural, multilingual participants with type 2 diabetes indicated the importance of group or familial dynamics in meal decision-making [25], which corresponds with the findings documented in our pilot intervention, where although the intended recipient of the food box was designed for the index participant (Latina females with food insecurity and a BMI > 30), the emphasis on the whole household, via sufficient food quantity, was essential for program adherence. This pilot study highlighted the feasibility of integrating charitable food in the implementation of FIM, as community food banks are often already aware of and cater to the cultural preferences of their patrons. When modifying FIM interventions for different populations, it is critical for food providers to simultaneously address the incorporation of culturally relevant foods and to enhance the inclusivity of various home food environments for optimal program adherence and patient health outcomes [26].

Latina females in this pilot study experienced significant improvements in food security, but not consumption of fruits and vegetables. The lack of increase in produce consumption may be related to not providing evidence-based nutrition education in conjunction with the grocery boxes. Indeed, the participants expressed a need for nutrition education as part of the intervention in the qualitative interviews. The goal of this pilot was to assess the acceptability and feasibility of a medically supportive grocery box to provide in conjunction with a culturally tailored behavioral intervention in a future trial for Latina females [27,28].

Medically supportive groceries are one of the forms of FIM that is supported by Section 1115 Medicaid Demonstration Waivers, such as CalAIM in California. The duration of FIM programs differs by state; for example, California provides reimbursement for ≤12 wk, whereas New York supports ≤6 mo [29]. As diet-related chronic diseases disproportionately impact Latinx and low-income communities, determining optimal FIM implementation strategies in this population is critical for reducing healthcare expenditures [30]. Given the limited duration for FIM reimbursement in California, in addition to providing food for disease management, nutrition education and behavioral lifestyle modifications are fundamental to initiate and sustain health behaviors. The healthcare and community partners were able to use the findings and recommendations from this pilot to inform a comprehensive FIM intervention, Vida Sana y Completa (Healthy and Complete Life), including medically supportive groceries and a culturally tailored behavioral lifestyle intervention [27,28].

Several partners came together to successfully implement this medically supportive grocery program including healthcare, the charitable food network, and volunteer organizations. This required weekly meetings, developing new workflows for sharing information about patient needs, and balancing each partners’ resources. This underscores the importance of supporting partnerships between healthcare, food partners, and other CBOs to successfully implement FIM interventions. Other studies with Latina females have also emphasized the importance of engaging partners in the design of FIM to promote acceptability and feasibility [14]. This pilot highlights the needed resources for supporting successful implementation models, even on a small scale as observed in this pilot study with 25 Latina females. Adequate resources and potentially new models will be needed to scale FIM to the 18 million households experiencing food insecurity and particularly to those with diet-related chronic diseases [1,2].

Limitations

This pilot study had several limitations that are important to consider, including the limited sample size, lack of a control group, and limited measurements given the pilot nature of the study. The limited sample size may reduce the generalizability of the findings and may not represent the broader population of Latina females at risk for diet-related chronic diseases. The pre/poststudy design with no control group inhibits the ability to determine if the changes observed were solely due to intervention effects. Finally, due to the pilot and exploratory nature of this study, dietary outcomes were limited to self-reported vegetable and fruit intake, although more nuanced and robust dietary measures may have captured changes in lean protein and whole-grain intake. Future studies should include larger sample sizes, a randomized controlled trial design to examine the effectiveness of a multicomponent FIM program, and more comprehensive outcome measures.

In conclusion, this pilot study demonstrated that a medically supportive grocery program is feasible and acceptable for Latina females with diet-related chronic diseases. The findings from this pilot will continue to inform comprehensive FIM interventions that include medically supportive groceries and culturally tailored behavioral interventions aimed at preventing diabetes and other diet-related chronic diseases among diverse populations. Additional research in other racial/ethnic minority and/or low-income groups should be explored to determine the appropriate modifications for FIM interventions to reduce diet-related chronic disease risk factors and improve overall health.

Author contributions

The authors’ responsibilities were as follows – LGR, PRE: conceptualized and designed the research study; PRE, YMM, W-tC: collected data; PRE, YMM, LX: performed statistical analysis; PRE, YMM, MDR, LGR: drafted the manuscript; and all authors: provided critical review and read and approved the final draft of the manuscript.

Data availability

The data described in the manuscript, the thematic code book, and analytic code will be made available on request pending corresponding author (LGR) approval.

Sources of support

This work was supported by the National Center for Advancing Translational Sciences of the NIH under Award Number UL1TR003142.

Conflict of interest

The authors report no conflicts of interest.