A total of 29 participants attended the six focus group discussions (four in English and two in Spanish). Participants represented various age and racial groups, with the majority (26) female. (Table 1)
Predominant Barriers to Fruit and Vegetable Consumption
Participant-reported barriers to FVC fell within three interrelated categories: affordability, accessibility, and desirability (Fig. 1).
Affordability concerns encompassed lack of money to buy food as well as the high price of fruits and vegetables. When asked about their biggest worries regarding food in general, participants’ most salient response was overwhelmingly lack of money.
“I have $35 a month for food. And that’s like barring the costs of gas going up, or anything going wrong, or needing an oil change for my car” (English-speaking female, Group 2).
Making sure their children had enough food was a significant stressor, to the extent that some participants reported rationing or forgoing food themselves.
Participant 1: “But I just don’t eat to make sure that they [my children] are fed.”
Participant 2: “I’ve done that.”
Participant 1: “As long as I know that they’ve eaten and that pertains at least a vegetable, whatever it is, the other side I choose, and they get their protein.”
Participant 2: “And you eat what’s left on the plate” (English-speaking females, Group 1).
When asked specifically about consuming fruits and vegetables, caregivers maintained affordability as the biggest barrier.
“If parents could find cheaper vegetables, we would be able to buy them” (Spanish-speaking Female, Group 4).
Participants considered “healthy foods” (fruits and vegetables) more expensive than other foods and could only consider purchasing them after paying for other necessities. As one participant explained:
“If in this pay period everything has been paid, and I have a little extra […] I let my daughter, pick out, she’ll pick up fruits” (English-speaking female, Group 2).
“ I’m on disability and by the time I pay my rent, my lights, my water, my gas and everything is taken care of, what I need, my personal needs, cause I budget, there’s nothing left for me to have in the bank but $25-how do you make it? That’s called knees and pray. You know how you get on your knees and you start praying… And the healthy stuff that you really do need, you really can’t get it” (English-speaking female, Group 6).
Even within meal planning decisions, participants often regarded fruits and vegetables as an “extra” that they had to forgo in order to afford what they considered more substantial, essential staples.
“It’s just considering things that are a meal and prioritizing. So, if we have spaghetti, you know that’s our meal and that’s the money... A lot of times, I see vegetables and fruit as extra, or a side, or a snack. So, we can’t get snacks today but we have a meal” (English-speaking female, Group 2).
Expense of fruits and vegetables was a concern for participants trying the stretch their food budgets to feed large families:
“Not only is it expensive, when you got 5 kids […] A bag of oranges are gone in a day, an hour” (English-speaking female, Group 1).
Participants also talked about difficulties in accessing affordable, quality fruits and vegetables, including frustration with the lack of transportation and lack of stores selling healthy foods within their neighborhoods.
“Nothing is close, might have to take several buses to get to the grocery store or buy food at a [gas] station where they mark food up 500%” (English- speaking female, Group 3).
“Well, I don’t usually know where to buy [fruits and vegetables] at a lower price” (Spanish-speaking female, Group 4).
Participants identified accessibility challenges as a major reason for underutilization of the hospital’s pilot food prescription program, as prescriptions could only be redeemed at one mobile market. No participants had actually visited the market or redeemed their $5 “prescription” and only two remembered hearing about the market. They cited inconveniences including the highly variable schedule of the mobile market, the short length of stops (typically one hour) and the unavailability of non-produce items, requiring parents to make an extra shopping trip. One participant described,
“It’s so hard to pinpoint where it’s [mobile market] going to be…and then about the time you get to one spot, it has moved to another spot” (English-speaking female, Group 6).
Participants also identified accessibility barriers to community food assistance programs, including eligibility restrictions for WIC and SNAP (income restrictions, age limits) and limited hours and long lines at food pantries.
Participant 1: “You have to get up at about 5:00 or 6:00 in the morning, sit outside in a line and it don’t start until 8:00 or 9:00”
Participant 2: “I know, that’s a whole day then” (English-speaking females, Group 3).
“There are days that they give it to you for free. But if a whole bunch of families go […], there is no more food left.” (Spanish-speaking female, Group 4).
Access to quality fruits and vegetables was especially challenging to families relying on food pantries. One participant described the produce at pantries as “on the edge of expiration” (English-speaking female, Group 2). While they did not prefer canned goods, several participants saw them as the only option for obtaining fruits and vegetables at food pantries. Families who did not have easy access to pantries faced additional barriers related to affordability and desirability, a choice that one participant explained was impacted by the low quality of pantry food:
“I can see a pantry desert […] When you look at the economics of it and the price of gas…the time and gas is not worth what the pantries distribute” (English-speaking female, Group 3).
Participants also identified several challenges of desirability, or the demand and preference for fruits and vegetables in their families. Participants described desirability barriers including children’s picky eating habits, time and effort required to prepare or cook, as well as cultural traditions. Many parents wished their children favored vegetables, as children’s preferences often led to difficulties cooking meals the entire family would eat.
“When I go on a diet or I try to eat healthier, I have to cook a meal for myself, a meal for my kids, and a meal for my husband. Yes, I have to cook three different meals for them. If we could all eat healthy together, then it would be different” (Spanish-speaking female, Group 4).
“Sometimes I do that [add fruits and vegetables] but my husband always put it at the side and my kids look at him and they try to do the same. Then I get into a dilemma and say, ‘eat it.’ The kids ask ‘why my father didn’t eat it?’” (Spanish-speaking female, Group 5).
“My daughter, she is not a fan of vegetables” (English-speaking female, Group 3).
With fruits and vegetables already considered more expensive, low desirability, particularly for vegetables, added an additional deterrent. Parents often saw purchasing fruits and vegetables or trying new dishes as a risk, wasting money on foods their children would not eat.
“I tell them, ‘I spend so much money and you are not even eating it.’ And they will go after the bread and open the refrigerator to make themselves a hot dog or a sandwich. I think, ‘Well that would have been faster to make than cooking’” (Spanish-speaking female, Group 4).
“I don’t know how to give them a variety of foods. Like meat with vegetables, chicken with vegetables and then what do I make? … And if I try to cook a new meal for [my children], they will say ‘Ah mommy, I don’t like that,’ or ‘I don’t want it.’” (Spanish-speaking female, Group 4).
Participants also perceived a high investment of time to purchase and prepare fruits and vegetables, making them less desirable options.
“When someone goes to the doctor’s visit and they ask if we give our kids vegetables, well we are honest and answer no because it is easier for us to buy McDonald’s, a Happy Meal or something. Because when some parents work, it’s harder for us to cook” (Spanish-speaking Female, Group 4).
Participants in five of the six groups also described fresh fruits and vegetables as less desirable because of their shorter shelf life.
“Because it [fruits and vegetables] only lasts so long. You buy it today and bananas be spoiled by tomorrow…” (English-speaking female, Group 6).
Many Hispanic parents identified struggles to eat healthy when fruits and vegetables are not a typical component of their meals. Hispanic parents in particular spoke about how they cook with a lot of red meat and grease, consistent with their families’ preferences and habits.
“We eat a lot of grease. Like I will make red hot chile with pork meat because my kids like it a lot. And it is easier because you just put a slab of meat and some beans and then they eat. To add vegetables and all that is really expensive” (Spanish-speaking female, Group 4).
(1) Offer direct assistance and linkages to external resources: As affordability was the most significant barrier discussed, parents suggested healthcare institutions offer direct assistance in the form of coupons or onsite food (i.e. bags of fruits and vegetables, onsite pantry). Coupons were most preferred, but participants thought a higher amount, redeemable at more convenient locations would make the program more successful than the pilot food prescription program.
“$5 would be okay, but if they were to give $20, I would say it’s worth taking and not losing out on it. And I could use it at whatever store I go to, or where I buy the most produce” (Spanish-speaking female, Group 4).
Participants also recommended that healthcare institutions connect families with existing community resources (affordable housing, affordable childcare, community food resources) to alleviate overall financial constraints.
“There’s so many different programs, not just food related. Childcare assistance and stuff like that. So many programs out there that I had no clue […] So, I think just being able to give the parents the resources and telling them about the programs” (English-speaking female, Group 2).
(2) Advocate for maintaining or expanding federal and community programs: Participants across groups noted that benefits programs like WIC, SNAP, and school lunches alleviate cost and increase accessibility of fruits and vegetables.
“If it wasn’t for WIC, then there’d probably be times that we didn’t have any [fruits and vegetables] in our house” (English-speaking female in group 2).
In addition, parents valued SNAP, especially when extra benefits were offered (extra funds for summer months, or double dollars for farmer’s markets) as well as school food programs:
“What’s most helpful is making sure she [my daughter] gets to school or is in some type of program that provides food. So that I know that she’s ate […] making sure that she’s at school every day, because I know she’s gonna eat something” (English-speaking female in group 2).
However, parents experienced hardship when their children aged out of WIC benefits, and many expressed difficulties with eligibility for SNAP. Because participants consistently cited WIC, SNAP, and school lunch as most helpful for their children consuming fruits and vegetables, expansions of these programs could alleviate barriers, without creating additional access challenges for families. Participants saw the role of healthcare provider as a leader in child health policies, and potentially effective advocates for expanding food assistance programs or broader community policies impacting overall household financial stability, and consequently, nutrition and health.
“…If they [healthcare providers] could advocate for cheaper housing […] then it would be easier to have more food money” (English-speaking female, Group 2).
“I feel like [The hospital] is such a huge presence in [the city]. If they were like, ‘There are parents that are not able to get better jobs because they can’t afford the gap between when they get paid and you know the childcare,’ even if they would just like to have some kind of forum where they met with city leaders [and say], ’This is what we’re hearing from our side of the community and this is what we’re concerned with, being medical people.’” (English-speaking female, Group 2).
(1) Integrate services into “my routine”: Participants recognized the ease of using programs like WIC and SNAP where they could access benefits at times and places that were already “within the routine […] it wasn’t an extra trip” (English-speaking female, Group 3).
Participants recalled positive experiences with healthy vending options at hospitals and with programs that were tied to routine activities such as healthcare or grocery store visits that gave free pieces of fruit to children.
(2) Communicate programs opportunities often, through multiple channels: Participants felt they would be more likely to access programs if they were publicized in multiple ways and times. Some recalled existing community gardens that were underutilized because people did not know how to get involved. Participants suggested that hospital-based programs (like gardens, educational classes, and support groups) be publicized through their provider during clinic visits, calls to make appointments, appointment reminders, as well as through clinic memo boards, flyers, websites, email and postal mailings.
(1) Involve children or whole family: Participants emphasized the importance of involving children in programming, particularly in discussions about community gardens, workshops, or rewards programs. In talking about a community garden at the healthcare institution, one participant said,
“If I got to go and work up there. Ya know, volunteer, then I don’t have to pay for it and I’m actually giving too. If you had kids that could handle something like that, bring your kids, and then they get the opportunity to give back too. And help their self-esteem” (English-speaking female, Group 1).
About cooking classes, another said,
“Have the kids in the same group with us, so that way they are interacting too. Because it’s not just us, it’s our kids that have to eat this too, so it should be their opinion too” (English-speaking female, Group 6).
(2) Utilize the unique influence of healthcare providers: In discussing what helped, participants talked about the influence providers can have in promoting FVC. Participants had several programmatic ideas that addressed desirability of fruits and vegetables, many of which involved the healthcare provider as an influencer. For example, fruit baskets at visits and rewards programs would incentivize providers to engage with children, creating positive reinforcement for healthy eating. Healthcare providers could also give handouts with information about healthy cooking or addressing specific nutritional needs.
“If you tell your doctor, ‘My child isn’t eating right, or he isn’t eating healthy,’ then the doctor will say, ‘Oh look, here is a class we have if you’d like to participate.’” (Spanish-speaking female, Group 4).