Stakeholders Must Consider All Aspects of Produce Prescription Programs
There are several concerns associated with produce prescription programs, despite the benefits to patients.
Produce prescription programs aimed at improving dietary options for people while encouraging preventive health measures must acknowledge the critical role played by both farmers and healthcare professionals and must determine whether such programs will use existing government assistance programs to identify patients with low income, diet-related health problems, or both of these issues.
A number of produce prescription programs have been initiated. Physicians identify patients with a qualifying diagnosis — diabetes, obesity, or celiac disease — or with a low income, or with both a qualifying diagnosis and low income, and write prescriptions for subsidized food high in nutrition, including fruits and vegetables. The federal government has proposed $4 million for produce prescription pilot programs for each fiscal year 2019 through 2023 as a part of the Agricultural Improvement Act of 2018.
In an article published in the AMA Journal of Ethics, Haley Swartz, MPP, explored the ethical and policy implications of produce prescription programs. She conducted a literature search to identify 19 articles on produce prescription programs. Of these articles, 14 included individuals of low socioeconomic status; 5 of the studies involved populations outside the United States. Ms Swartz used an ethical matrix to evaluate well-being, autonomy, and fairness from the perspective of patients and patient families, participating local farmers, healthcare professionals, and government assistance programs.
Ms Swartz identified 5 prescription types: farmers' markets were the primary source of food for most individuals in the study; others included locally owned grocery stores, local branches of national stores, community gardens, and mobile markets. Two programs gave participants a choice of where to shop, either a farmers' market, community garden, or participating grocery store, and 9 programs offered vouchers to subsidize participants.
Ms Swartz noted a number of positive effects of produce prescription programs, including the opportunity to promote healthy behaviors, the use of family-based approaches and benefits to local farmers in terms of increasing revenue and community engagement. However, programs can be unreliable from one season to the next and so may contribute to economic instability among local farmers. Farmers who are forced to absorb the cost of subsidized produce may not be able to participate in the program, and patients may experience coupon stigmatization, leading to embarrassment and discrimination.
The review found that no programs currently use federal assistance programs such as Medicaid, the Supplemental Nutrition Assistance Program, or the Special Supplemental Nutrition Program for Women, Infants, and Children. Ms Swartz suggested replacing the prescription with an electronic benefit transfer card to remove the stigma associated with vouchers. She also called for research to determine whether produce prescription programs remain effective if they only serve as guidance rather than offering a financial incentive. She called for researchers, clinicians, and other healthcare stakeholders to design the incentive structure, while taking into account the critical role played by physicians, local participating farmers, and government assistance programs.
Swartz H. Produce Rx programs for diet-based chronic disease prevention. AMA J Ethics. 2018;20:E960-E973.