A Contextual Evaluation of the Fresh Fruit and Vegetable Program in South Carolina and Related Child Health Behaviors

Children in vulnerable communities are at increased risk for poor diet.1,2 The Fresh Fruit and Vegetable Program (FFVP) is a United States Department of Agriculture (USDA) child nutrition program that increases vulnerable children’s access to and consumption of fruits and vegetables.3,4 FFVP is inherently flexible,5 has few regulations, and helps identify and develop best practices for individual schools to increase fruit and vegetable consumption among low-resource children.6 Flexibility built into the FFVP at the federal level naturally results in a variation of program adoption and implementation at both the state and school-levels.7 These variations affect outcomes in complex health promotion programs.8–10 However, few studies have examined how variation presents in FFVP schools and its associated impacts.3 To better understand the effects of FFVP adoption and implementation variation on student health behaviors, the Principal Investigator (PI) conducted a mixed-methods study in the Spring of 2018 examining two specific aims. The first aim explored why some eligible schools in South Carolina apply for the FFVP grant while others do not and how school stakeholders decide to apply for the FFVP grant. The second aim explored if children in FFVP schools consumed more significant amounts of fruits and vegetables compared to children in non-FFVP schools, if school-level characteristics affected FFVP implementation variation, and if FFVP implementation variation increased student consumption of FFVP snacks. Both aims used data collected from fourteen low-resource schools in South Carolina. The South Carolina Department of Education supplied a list of schools operating FFVP in the 2017-2018 school year. The PI randomly selected schools from the provided list representing the four regions of SC (Upstate, Midlands, Pee Dee, and Low Country) then matched the seven FFVP schools demographically and regionally with seven schools not operating FFVP. In addition, the PI conducted observations of lunch and snack service and interviews in each school. To address specific aim one, the PI purposively selected stakeholders in three groups: stakeholders in FFVP funded schools, stakeholders in schools not operating the FFVP, and state FFVP administration. The PI completed a total of fifty-seven interviews with seven different categories of school stakeholders, including 15 school administrators, 14 school foodservice directors, seven school cafeteria managers, four school FFVP coordinators, seven teachers, seven parents, and three state officials. Based on this sample and these specific aims, school stakeholders apply for the FFVP grant if they feel the program will benefit their children, feel a moral imperative to address injustices, believe they are eligible and can manage the administrative burdens of federal grants. To address specific aim two, the PI collected a sample of 3849 independent student lunch and FFVP snack consumption observations nested in 88 4th and 5th-grade classrooms. All observations were considered independent, and all data was de-identified. Following school observations, the Principal Investigator (PI) constructed a data set including publicly available school profile statistics, school health index scores, plate waste observations, and a calculated FFVP implementation score for inclusion in this analysis. The analysis included two sample T-Tests, pairwise correlation, and multi-level models. Based on this sample, students at FFVP schools consume significantly more fruits and vegetables when compared to students in non-FFVP schools (p Children in vulnerable communities are at increased risk for a poor diet. Federal nutrition safety-net programs like the FFVP can help to mitigate this risk through increased access and consumption of fruits and vegetables during the school day. To effectively reduce the burden of poor diet through the FFVP, schools need to be aware of the program, prove eligibility, apply, adopt, and implement the program. Understanding the perspectives of eligible school stakeholders as to why they may or may not apply for the FFVP can help elucidate how to improve application rates to the program and understanding how program variation affects student behaviors can improve program outcomes. This study suggests that stakeholder motivations for application emphasize context surrounding child welfare and moral imperatives in addition to eligibility systems and capacity. Additionally, while students in FFVP schools consume more fruits and vegetables than students in schools not operating the FFVP, variation in program implementation can impact how much of the FFVP snacks students consume. This research can help the United States Department of Agriculture and implementing agencies continue the expansion of the FFVP into vulnerable communities. Framing the FFVP to benefit children can potentially drive applications as school stakeholders unanimously agree that child welfare is their primary reason for seeking the funds. This research also provides insights into FFVP efficacy. Program implementation appears to be influenced by school location, targeted resource sharing, capacity building, and training vital for the rural and fringe schools struggling to implement the program entirely. A final aspect of program implementation often overlooked is the influence of the classroom on student behaviors. Based on the multi-level model, the classroom does explain some of the variations in student consumption of the FFVP fruit and vegetable snack, indicating that some standardization may need to be pursued at the school level to improve program outcomes