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Improving Access to Fresh Produce - Collaboration of the DOH Manatee WIC Program and the Food Bank of Manatee
Shelly Travers Smith
Public Health Nutrition Program Director
shelly.smith@flhealth.gov
941-708-6170
Bradenton
FL
34208
Your summary must address all the questions below:
The Department of Health - Manatee County is a large health department located on the central west coast of Florida. Health department services include Clinical Services, Community Health, Disease Control and Prevention, Vital Statistics and the Women, Infants and Children Food Supplementation Program (WIC).
According to the United Way ALICE report, of the 142,465 families in Manatee County, 44% fall below the ALICE threshold. Currently, there are 10,593 estimated WIC eligible participants in Manatee County (pregnant, breastfeeding, infants and children under age of 5), and DOH-Manatee’s WIC program is currently serving 61.6%. According to FLWiSE (WIC reporting database for Florida), “Racial and Ethnic Participation report for November 2019, demographics for WIC participants was white-75.3%, black/African American-24.7%, Hispanic/Latino- 51.8%.
According to the Florida Environmental Public Health Tracking website, the number of people living within 1/2 mile of a healthy food source is 23.95%, or almost one-quarter of the population in Manatee County. In addition, DOH-Manatee is currently located in a USDA designated food desert (food desert = low access to healthy foods in an area where a high proportion of residents are low income). In Manatee County, 30% of residents are considered to have low access to healthy food (2016 report to Manatee County Government). FLHealthCHARTS Healthiest Weight profile shows that adults who are overweight in Manatee is 39.7% as compared to Florida at 35.8%. FL WiSE program indicators reveal that 16.1% of WIC children over the age of 2 years in Manatee are overweight, as compared to Florida at 14.5%; 15% of WIC children in Manatee are obese, as compared to Florida at 13.4%. The DOH-Manatee WIC program promotes breastfeeding for infants, as studies indicate that breastfed infants have a lower incidence of obesity and breastfeeding mothers tend to lose pregnancy weight more quickly. FL-WiSE data from September 2019 indicate that 81.8% of infants at Manatee WIC were ever breastfed, as compared to Florida at 83.6%.
In April 2018 a collaboration between DOH-Manatee WIC program and the Food Bank of Manatee was developed to increase access to fresh produce for pregnant women attending the WIC Breastfeeding class and improve access to additional produce for WIC participants, impacting the rate of childhood obesity.
On Wednesday and Friday mornings, the Food Bank of Manatee delivers the produce to the DOH Manatee WIC clinic. After produce bags are prepared for clients scheduled for the Breastfeeding classes, other clients are provided a bag to fill with produce of their choice. WIC staff provides recipe ideas to clients for the produce.
The donation quantity varies from 200 pounds to 500 pounds of fresh, in season produce. To date this collaboration resulted in a donation of 62,081 pounds of fresh produce valued at $41,594.27 (valued assessed at $0.67/pound per Cindy Sloan, Food Bank of Manatee Director).
As a result of this practice, attendance at the WIC Breastfeeding class more than doubled, from 10 in March 2018 to 25 as of September 2019. Infants ever breastfed increased from 76.1% to 81.8% and the percentage of overweight/obese children decreased from 30.3% to 29.3% for the same time frame.
Generous produce donations have impacted other WIC recipients and residents in the adjacent neighborhood. A line forms every Wednesday and Friday morning to receive the fresh produce. WIC clients are sampling foods they never had the opportunity to try. They learn what produce is in season to better use their WIC benefits and neighborhood residents learn more about services at DOH Manatee.
The objectives met include the increase in percentage infants ever breastfed and attendance at the Breastfeeding class. The improvement in overweight/obese children provides a platform for additional activities to impact this group.
The success of this practice is due to the generosity of the Food Bank of Manatee and the support of the WIC team. WIC staff attractively display the produce, encourage participants to try new items and provide recipe ideas. Clients scheduled for the Breastfeeding class are informed of the incentive.
The public health impact of this practice is to increase access to fresh produce to WIC participants, increasing the variety of healthy foods to decrease the incidence of overweight/obese children and increasing breastfeeding education and support to increase the percentage of infants breastfed.
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
The DOH Manatee WIC program used collaboration with an existing partner to focus a specific population – WIC families with limited access to fresh produce. The WIC program certification process includes an income component set at 185% of the poverty level. Fresh fruits and vegetables should be consumed daily for good health, especially during times of growth; pregnancy, infancy and childhood to age 5. Families with limited income and transportation, residing in a food desert in Manatee County do not have access to this basic need.
The target groups in WIC clients in Manatee County were initially pregnant women and children who were overweight/obese. The initial collaboration agreement between the Food Bank of Manatee and DOH Manatee WIC Program was to increase the availability of fresh produce to participants of the Breastfeeding class. This class provides pregnant women with education about breastfeeding, infant feeding and the support the WIC program in Manatee can provide, such as breastfeeding peer counselors, a breastfeeding hotline and loaner breast pumps. Participation in this important class was lower than desired as reflected by attendance records and rate of infants who were ever breastfed.
Overweight/obese children risk early onset of chronic health conditions such as heart disease and diabetes. During individual WIC nutrition counseling we learned that lower income families were not likely to use WIC produce benefits to try new fruits and vegetables. Instead the $9 allotment was used on familiar items such as potatoes, bananas and apples. Families were encouraged to select produce that was in season to help extend their benefit with more variety. The collaboration with the Food Bank of Manatee allows families to introduce new fruits and vegetables to children, encouraging the intake of nutrient-rich foods.
In DOH Manatee WIC Program the overweight/obese nutrition risk code was assigned to 54.9% of the breastfeeding women. Indicators reveal that 61.1% of the pregnant women were overweight or obese at pre-pregnancy, 8.3% of children were obese and 10.9% of children were overweight. Including more nutrient-dense vs. calorically-dense foods can improve the diet of those who are overweight or obese. This collaboration allows an increased access to nutrition- dense foods to families with lower income, limited transportation and residence in a food desert.
This innovative practice improves access to fresh fruits and vegetables. Each Wednesday and Friday morning, a line forms in anticipation of the Food Bank delivery. The produce, which many times is organic, arrives at the WIC clinic and is displayed in an area adjacent to the lobby. It is overseen by WIC staff who first prepare bags of produce for each scheduled attendee of the Breastfeeding class. Clients in line receive a bag to fill with produce of their choosing. Children often assist parents in selecting the items they wish to try. This collaboration between the Food Bank of Manatee and DOH Manatee WIC Program has allowed more than just WIC benefits to be offered to our families. Clients learn about new fruits and vegetables and recipes are shared. Many families participate every day the produce is offered and share that without this practice they would not be able to serve fresh vegetables to their families on a regular basis. One mother was excited to select mushrooms – a luxury for her as she loves them but is reluctant to spend her limited income on something her family has not tried.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
The goals and objectives of the collaboration of DOH Manatee WIC Program and the Food Bank of Manatee are:
To increase access to fresh fruits and vegetables to participants of the WIC program in Manatee County.
To increase participation in the WIC Breastfeeding class by providing an incentive of fresh produce at the class.
To increase the percentage of infants who are ever breastfed by improving access to education and support for pregnant women at the Breastfeeding class.
To increase access to nutrient dense foods and expand produce offerings for children who are overweight/obese.
Steps taken to implement the program included:
Steps to implement the practice include coordination for delivery of produce as well as an accessible area to safely display the items. The Food Bank of Manatee secures drivers and a refrigerated truck to transport the fresh produce from their warehouse to the main WIC clinic. The WIC clinic supplies a large cart for the driver’s use in delivering the produce. The driver provides the WIC team member with the weight of the produce delivery and unloads the produce from the truck, transports it into the WIC clinic and provides shopping bags for clients to select their produce items. The WIC staff assist in unloading the cart and displaying the produce. The number of appointments for the breastfeeding classes is obtained and WIC staff prepares bags of produce for each client scheduled for the classes. The remaining produce is offered to WIC families. Adults are provided a shopping bag to select their items. Once the initial line dissipates, WIC staff invites served clients to partake of the produce donation. Any excess produce is offered to the Clinic Services at the Main Health Department location or stored in the refrigerator and taken to a satellite WIC clinic the following day.
The selection of the Breastfeeding class attendees to receive the produce as an incentive for attendance was in effort to improve attendance at the class which was at 10 participants/month in March 2018 and the infants ever breastfed indicator which was at 76.1% during the same timeframe. Selection criteria included an ability to address the obesity rates in Manatee, 31.1% for children participating in the WIC program in Manatee County and 39.7% for adults.
In Manatee County 30% of the residents are considered to have limited access to fresh foods and the LHD is situated in a food desert. Providing access to these individuals and sharing of the services offered at DOH Manatee such as the community garden, may improve access to necessary nutrients for good health.
The timeframe for this practice was April 2018 – present. The ongoing generosity of the Food Bank of Manatee and determination of the WIC staff at DOH Manatee allows the program to continue and flourish.
DOH-Manatee partners with community organizations and individuals to conduct a Community Health Assessment and a Community Health Improvement Plan. An important part of this assessment includes public feedback regarding the greatest areas of need to improve health and quality of life in our community. The Manatee Healthcare Alliance meets monthly to track indicators and address gaps with innovative solutions.
There were no startup costs for the DOH Manatee WIC Program to institute this practice. Staff assisting in the setup of the produce were already scheduled to provide services. The Food Bank of Manatee provides the produce, transportation, driver and shopping bags at no cost to the program. Future plans include researching the feasibility of eco-friendly shopping bags for clients.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
We learned that people want to eat healthy when possible. We learned that access to healthy food can impact the diet. Our objects were achieved.
Objective 1 - To increase access to fresh fruits and vegetables to participants of the WIC program in Manatee County. The Food Bank of Manatee delivers fresh produce to the DOH Manatee WIC program each Wednesday and Friday morning. The program initially was delivery only on Wednesday, the day of the Breastfeeding class. The popularity of the program was so great, with hundreds of pounds of fresh produce gone within a few hours, that an additional day was added, and the quantity of the delivery was increased from 1299 pounds in March 2018 to 3318 pounds of produce in November 2019.
Objective 2 - To increase participation in the WIC Breastfeeding class by providing an incentive of fresh produce at the class. The Breastfeeding classes at DOH Manatee are offered every Wednesday, one class in English the other in Spanish. In March 2018 only 10 clients attended the class. The addition of the incentive of a bag of fresh produce has increased attendance by 150% to 25 clients in September 2019. As more pregnant women are educated about the benefits of breastfeeding, more are willing to try breastfeeding their infants.
Objective 3 - To increase the percentage of infants who are ever breastfed by improving access to education and support for pregnant women at the Breastfeeding class. DOH Manatee WIC program staff includes certified lactation consultants and breastfeeding peer counselors to support breastfeeding mothers. WIC breastfeeding monitoring quarterly indicators of infants who were ever breastfed were 76.1% at the start of this practice in March 2018 and have increased to 81.8% as of September 2019.
Objective 4 - To increase access to nutrient-dense foods and expand produce offerings for children who are overweight/obese. The program has increased delivery of fresh produce from one to two days each week. The amount of produce delivered has also increased from 24,233 pounds in 2018 to 38,289 pounds in 2019. The quarterly WIC indicator identifying the percentage of children at a healthy weight has improved from 66.1% in March 2018 to 67.4% in September 2019. Offering opportunities for families to try new fruits and vegetables is an important factor in improving the quality of their diet.
The practice is evaluated quarterly, when new WIC indicators are released. Quantities of produce delivery and their monetary value are reported to the DOH Manatee Health Officer monthly. Modifications to the practice included the location of the displayed produce and the process of providing first access to the breastfeeding class participants. Initially the produce was displayed in a secured hallway located outside the Breastfeeding Classroom. As the quantity of produce increased and the delivery time became earlier, the location was changed from the back of the WIC clinic to a front reception area adjacent to the WIC lobby, for all clients to easily access and within view of WIC staff for monitoring. Bags of produce were prepared for the breastfeeding class participants since those classes were scheduled for 9am and 3pm. Once those bags were prepared, other clients were invited to fill 1 bag with the remaining produce of their choosing.
Modifications to the practice due to the data obtained included recipe sharing as part of the nutrition education and outreach to community partners to both increase WIC participation and access to fresh produce.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
Providing the tools for clients to achieve goals improves outcomes. Nutrition and breastfeeding classes provide valuable information. If the client does not attend the classes, then the education cannot be shared. Offering an incentive for participation, especially a desired incentive, has a positive impact on the objective. WIC Manatee’s objective to increase the WIC quarterly indicator of infants ever breastfed was achieved by increasing participation in an existing class with the use of an incentive. The long-term outcome of increasing the percentage of infants who are breastfed was not measured in this practice. Breastfed infants have a lower infant mortality rate and tend to have a reduced incidence of childhood obesity. As the practice continues the desired outcome is a reduction in childhood obesity.
The Food Bank of Manatee is committed to sustaining this practice as it meets their goals to improve access to food to those in need. The DOH Manatee WIC program is committed to continuing this practice. Outreach from the DOH Manatee WIC and Community Health divisions inform stakeholders of the practice to encourage referrals to the program
. In 2017, we received the Model Practice Award for “A Regional Approach to Implementing Community-Drive Healthy Food Access in Underserved Communities.”
