Systematic Review of Factors Influencing Farmers' Market Use Overall and among Low-Income Populations

Local Food System Approaches to Address Food and Nutrition Security among Low-Income Populations: A Systematic Review

Food and nutrition insecurity disproportionately impact low-income households in the United States, contributing to higher rates of chronic diseases among this population. Addressing this challenge is complex because of various factors affecting the availability and accessibility of nutritious food. Short value chain (SVC) models, informally known as local food systems, offer a systemic approach that aims to optimize resources and align values throughout and beyond the food supply chain. Although specific SVC interventions, such as farmers markets, have been studied individually, a comprehensive review of SVC models was pursued to evaluate their relative impact on food security, fruit and vegetable intake, diet quality, health-related markers, and barriers and facilitators to participation among low-income households. Our systematic literature search identified 37 articles representing 34 studies from 2000-2020. Quantitative, qualitative, and mixed-method studies revealed that farmers market interventions had been evaluated more extensively than other SVC models (i.e., produce prescription programs, community-supported agriculture, mobile markets, food hubs, farm stands, and farm-to-school). Fruit and vegetable intake was the most measured outcome; other outcomes were less explored or not measured at all. Qualitative insights highlighted common barriers to SVC use, such as lack of program awareness, limited accessibility, and cultural incongruence, whereas facilitators included health-promoting environments, community cohesion, financial incentives, and high-quality produce. Social marketing and dynamic nutrition education appeared to yield positive program outcomes. Financial incentives were used in many studies, warranting further investigation into optimal amounts across varying environmental contexts. SVC models are increasingly germane to national goals across the agriculture, social, and health care sectors. This review advances the understanding of key knowledge gaps related to their implementation and impact; it emphasizes the need for research to analyze SVC potential comprehensively across the rural-urban continuum and among diverse communities through long-term studies of measurable health impact and mixed-method studies investigating implementation best practices. This trial was registered at PROSPERO as CRD42020206532.

Perceptions of the double value coupon program in southern Illinois

Introduction

Purchasing produce at farmers markets represents one method by which individuals can purchase and have access to healthful and seasonal fruits. Despite the extension of nutrition assistance programs to local farmers markets, fruit and vegetables consumption has remained below the recommended guidelines, specifically in rural geographical locations.

Statement of purpose

The purpose of the study was to explore the aspects of the Link Up Illinois Double Value SNAP Nutrition Incentives Program (DVCP) and its effects on food selection at rural farmers markets for individuals enrolled in nutrition assistance programs.

Methods/approach

The current study uses a qualitative methodology in order to uncover barriers local health departments and farmers markets face to implementing the DVCP in their communities and to discover the perspectives of low-income individuals who utilize the DVCP. This paper explores the organizational and community member perceptions of the DVCP and its administration. Semi-structured interviews and one focus group were conducted with health educators from county health departments, DVCP stakeholders, farmers market managers, local farmers, and residents who used the DVCP. A purposeful sampling method was used, intentionally selecting individuals with lived experiences of the research objective. Data were analyzed using a three-cycle coding process, then categorized into overarching themes until thematic saturation was reached.

Results

There were a total of 19 individuals who participated in the study. Five themes and four subthemes emerged from data analysis, including organizational capacity, exposure to the DVCP, purchasing power, DVCP advancements, and values.

Conclusion/implications

These findings contextualize the facilitators and barriers of multiple stakeholders when implementing nutrition assistance programs at farmers markets. Other similar "double value" programs can utilize these lessons when seeking to increase participation of underrepresented populations at local farmers markets.

Impact of a farmers' market healthy food subsidy on the diet quality of adults with low incomes in British Columbia, Canada: a pragmatic randomized controlled trial

BACKGROUND

Adults with low incomes have lower diet quality than their higher income counterparts. In Canada, the British Columbia Farmers' Market Nutrition Coupon Program (FMNCP) provides coupons to low-income households to purchase healthy foods in farmers' markets.

OBJECTIVE

The objective of this study was to examine the impact of the FMNCP on the diet quality of adults with low incomes.

METHOD

In a pragmatic randomized controlled trial conducted in 2019, adults with low incomes (≥18 y) were randomly assigned either to an FMNCP intervention (n = 143) or a no-intervention control group (n = 142). The FMNCP group received 16 coupon sheets valued at $21 per sheet over 10-15 wk to purchase healthy foods from farmers' markets. Participants completed a questionnaire and 2 24-h dietary recalls at baseline (0 wk), immediately post-intervention (10-15 wk), and 16-wk post-intervention (26-31 wk). Diet quality was calculated using the Healthy Eating Index-2015 (HEI-2015). Linear mixed-effects regression assessed differences in HEI-2015 total (primary outcome) and component scores (secondary outcomes) between the FMNCP and control groups at post-intervention and 16-wk post-intervention. Subgroup analyses examined program impacts by sex and age group (18-59 y, ≥60 y).

RESULTS

There were no significant differences in HEI-2015 total scores between the FMNCP and control groups at post-intervention (-0.07; 95% CI: -4.07, 3.93) or 16-wk post-intervention (1.22; 95% CI: -3.00, 5.44) overall or between subgroups. There were no significant between-group differences in HEI-2015 component scores at post-intervention, although there were significant differences in component scores for dairy and fatty acids at 16-wk post-intervention.

CONCLUSION

The FMNCP did not significantly improve diet quality among adults with low incomes over the study period. Further research is needed to explore whether higher subsidy amounts or a longer intervention period is needed to meaningfully improve diet quality among adults with low incomes. This trial was registered at [clinicaltrials.gov] as [NCT03952338].

Community-based nutrition education and hands-on cooking intervention increases farmers' market use and vegetable servings

OBJECTIVE

The objective of the current study was to evaluate the impact of the Market to MyPlate (M2MP) program on participants' reported farmers' market (FM) attitudes and shopping behaviours, frequency of serving vegetables to their families, food resource management behaviours and food security. A secondary objective was to identify facilitators and barriers to shopping at FM and food waste reduction techniques used by low-income families.

DESIGN

The current study used a mixed methods evaluation embedded within a cluster randomised trial of the M2MP intervention.

SETTING

The 7-week M2MP program was delivered at Extension offices and community centres in central Illinois.

PARTICIPANTS

Participants included 120 adults and their families. Class cohorts were randomly assigned to one of three treatment groups: (1) nutrition education and cooking classes with produce allocations (PAE, n 39); (2) nutrition education and cooking classes only (EO, n 36) or (3) control group (n 45).

RESULTS

Compared with control participants, PAE participants were significantly more likely to report shopping at FM (P = 0·029) and reported serving more vegetables to their families (P = 0·010) (EO participants did not differ from the control group on any outcomes). There were no differences between conditions in survey-based measures of food security or food resource management behaviours. Interview results describe facilitators and barriers to shopping at FM and a variety of food waste reduction techniques (including food placement and food resource management).

CONCLUSIONS

These findings suggest that fresh produce provision coupled with nutrition and culinary education can positively impact shopping and dietary behaviours.

Investigating how COVID-19 has challenged the Eurocentric concept of 'development': a case for sustainable food systems in the UK

The COVID-19 health crisis has imposed extensive shocks to many global systems, particularly the UK food production chains, further challenging Eurocentric development discourses and stereotypes. Thus, this paper investigates how the pandemic has challenged the UK's development status by analysing how the pandemic has impacted the country's food industry. A literature review was conducted and used to identify, select and critically appraise publications between 2000 and 2021 discussing the challenges in the UK food system. The findings reveal that the UK's food industry is unsustainable as there are significant flaws in the system, that is food insecurity and food waste that go unaddressed. The impact of the pandemic has exacerbated the social and economic impacts of operating with such a system. Compounded with the geopolitical adjustments caused by Brexit, the UK is faced with the challenge of restructuring and developing new frameworks such as policies, regulations, schemes and partnerships to support the food industry's sustainability. Lastly, the findings reinforce that 'developed' and 'developing' nations encounter similar food challenges, which manifest differently in various landscapes and contexts. Therefore, the world (not just the UK) needs to shift away from Eurocentrism, moving towards a universal but equally personalised development outlook. This review provides an outline of the major problem areas in the UK food system and presents potential solutions aimed at helping guide the government's decision-making process.

An Investigation of Social Ecological Barriers to and Facilitators of WIC Farmers Market Nutrition Program Voucher Redemption

In the United States, many communities lack sufficient access to fresh produce. To improve access to fresh fruits and vegetables, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides eligible participants vouchers through the Farmers Market Nutrition Program (FMNP) that can be redeemed directly from farmers at markets or farm stands. However, FMNP voucher redemption rates in New Jersey remain lower than those in neighboring states. This article used the social ecological model to examine differences between FMNP participants who redeem vouchers (Redeemers) and those who do not (non-Redeemers) in the areas of: produce procurement practices and consumption frequency, and barriers to and facilitators of FMNP voucher redemption. This cross-sectional study included WIC FMNP participants (N = 329) in northern New Jersey, USA. Analyses were conducted using descriptive statistics, independent sample t-tests, and one-way ANOVA. Compared to Redeemers, non-Redeemers consumed fewer average daily vegetable servings, were more likely to shop at small grocery/corner stores, and encountered significant barriers to FMNP redemption, e.g., difficulty finding time to redeem vouchers.

Comparison of Fruit and Vegetable Prices between Farmers' Markets and Supermarkets: Implications for Fruit and Vegetable Incentive Programs for Food Assistance Program Participants

This cross-sectional study was part of a larger evaluation of a fruit and vegetable (FV) incentive program for Supplemental Nutrition Assistance Program (SNAP) participants in California. We examined the price differences in FV to explore whether these could help explain a previously observed lack of effect of the incentive program on FV consumption. Differences by type (organic/no-spray or conventional), among a convenience sample of farmers' markets (n = 11) and nearby supermarkets (n = 7), were assessed using Wilcoxon rank-sum tests adjusting for clustering by market. We calculated the cost of market baskets comprising recommended FV servings for a household using median prices to consider the implications of FV price differences for SNAP shoppers who use financial incentives for FV. We found that farmers' markets primarily offered organic FV while supermarkets primarily offered conventionally grown FV. Farmers' market prices tended to be lower than supermarkets for organic FV but higher for conventional FV. Compared to supermarkets, the market basket composed only of organic FV cost USD 16.34 less at farmers' markets, whereas a basket comprised of a mix of conventionally and organically grown FV cost USD 3.68 more. These differences warrant further exploration; FV price and type should be considered in studies aimed at understanding the impact of SNAP financial incentive programs.

Understanding SNAP Recipient Characteristics to Guide Equitable Expansion of Nutrition Incentive Programs in Diverse Food Retail Settings

Structural barriers, such as food costs, reduce access to healthy foods for populations with limited income, including those benefitting from the Supplemental Nutrition Assistance Program (SNAP). Nutrition incentive programs seek to address this barrier. Evaluations of SNAP-based incentive programming often focus on one setting (i.e., either farmers’ markets or grocery stores). We examined use patterns, characteristics, and preferences among 253 SNAP consumers with access to incentive programming at both a farmers’ market and a grocery store located within five miles of their home. Cross-sectional survey data were collected in 2019 in two Ohio cities. Despite geographic access, 45% of those surveyed were not using the incentive program; most non-users (80.5%) were unaware of the program. Program users compared to non-users had higher household incomes (p < 0.001) and knew more people using the program (p < 0.001). Grocery stores were the most common setting of use (59%); 29% used at farmers’ markets; 11% used in both settings. User characteristics varied by store setting based on demographics, program experience, fruit and vegetable purchasing and consumption patterns, and social dynamics related to use. Our findings support comprehensive awareness-raising efforts and tailored implementation of incentive programming that attends to diverse segments of SNAP consumers to promote equity in program reach.

A Preliminary Evaluation of Virginia Fresh Match: Impacts and Demographic Considerations for Future Fruit and Vegetable Incentive Programs

The purpose of this communication is to describe the preliminary evaluation of the Virginia Fresh Match (VFM) financial incentive program for fresh fruits and vegetables for Virginia Supplemental Nutrition Assistance Program shoppers and to determine if there were differences in incentive outcomes by race. In this cross-sectional study, a questionnaire was administered to shoppers using Virginia Fresh Match incentives at participating farmers markets and community-based food retail outlets. Repeated measures ANOVAs were used to detect differences in fruit and vegetable consumption between demographic groups over time. Chi-square tests were used to determine if there were associations between race and perceived impact of VFM incentives on making food last and the attribution of VFM incentives to changes in fruit and vegetable consumption frequency. Frequency of fruit and vegetable intake was significantly higher during VFM incentive use, with a difference of 1.17 ± 0.07 and 1.07 ± 0.07 on a Likert scale measure, respectively (p ≤ 0.001). There were racial differences in assertions that VFM incentives helped food to last. VFM incentives were effective at increasing fruit and vegetable consumption, but racial differences should be considered in the administration of VFM to avoid reinforcing systems or approaches that may contribute to disparities in food access and food security.

Toward Sustainable Communities: A Case Study of the Eastern Market in Detroit

Community development tends to focus on large-scale, government-funded transformations or on small-scale, grassroot initiatives. In the US, the financial resources, available infrastructure, and broad-based civic support to implement large-scale community transformations are frequently lacking. In contrast, niche interventions, while often locally successful, tend to be unscalable. Accordingly, many community development programs either do not go beyond an ideational stage, or they are unscalable or unsustainable in the long run. In this qualitative case study, we analyze the Eastern Market in Detroit, Michigan, a local institution that contributes considerably and in several ways to the sustainability of multiple communities. Using Content Configuration Analysis (CCA), we conduct a bottom-up exploratory analysis of fieldwork notes, nonparticipant observations, as well as audio, visual, and written materials including policy and strategy documents from the City of Detroit, Wayne County, and the State of Michigan, academic publications, strategy and annual reports, websites, blogs, vlogs, social media outlets, newspapers, podcasts, and interviews along two lines of inquiry: first, to examine how the market contributes to sustainable community development and, second, to explore the systemic underpinnings that facilitate such development. Specifically, we focus on the Eastern Market to identify system-relevant actors, interests, relations, interventions, and outcomes that illustrate an institution which operates well beyond the ideational confines of a conventional farmers market. In the process of exploring the adaptive nature of the Eastern Market within its financial and infrastructural constraints, we also exemplify with this case that a well-established institution, a farmers market, can reinvent itself to serve multiple needs of larger, heterogeneous communities, and that the successful adaptations associated with this reinvention reimagine the community in which it is embedded.

Feasibility of Delivering an on-Campus Food Distribution Program in a Community College Setting: A Mixed Methods Sequential Explanatory Investigation

Despite community college students experiencing food insecurity there has been a dearth of research conducted on the feasibility of providing a program designed to increase access to fruits and vegetables among community colleges. This study used a mixed methods sequential explanatory design to examine the feasibility of delivering an on-campus food distribution program (FDP) to community college students and to examine the association between FDP and food insecurity and dietary intake. The study also explored the student's experiences related to barriers and facilitators of program utilization. In phase one, the FDP occurred for eight months and students could attend twice per month, receiving up to 60 pounds of food per visit. Online questionnaires were used to collect students' food security and dietary intake. Among the 1000 students offered the FDP, 495 students enrolled, with 329 students (66.5%) attending ≥ 1. Average attendance = 3.27 (SD = 3.08) [Range = 1-16] distributions. The FDP did not reduce food insecurity nor improve dietary intake. In phase two, a subsample of students (n = 36) discussed their FDP experiences through focus groups revealing three barriers limiting program utilization: program design and organization, personal schedule and transportation, and program abuse by other attendees. Facilitators to greater program utilization included: the type of food distributed and welcoming environment, along with allowing another designated individual to collect food. To maximize program use, it is suggested that reported barriers be addressed, which might positively influence food insecurity and dietary intake.

Sustainable food systems and nutrition in the 21st century: a report from the 22nd annual Harvard Nutrition Obesity Symposium

Food systems are at the center of a brewing storm consisting of a rapidly changing climate, rising hunger and malnutrition, and significant social inequities. At the same time, there are vast opportunities to ensure that food systems produce healthy and safe food in equitable ways that promote environmental sustainability, especially if the world can come together at the UN Food Systems Summit in late 2021 and make strong and binding commitments toward food system transformation. The NIH-funded Nutrition Obesity Research Center at Harvard and the Harvard Medical School Division of Nutrition held their 22nd annual Harvard Nutrition Obesity Symposium entitled "Global Food Systems and Sustainable Nutrition in the 21st Century" in June 2021. This article presents a synthesis of this symposium and highlights the importance of food systems to addressing the burden of malnutrition and noncommunicable diseases, climate change, and the related economic and social inequities. Transformation of food systems is possible, and the nutrition and health communities have a significant role to play in this transformative process.

A Rapid Review of Territorialized Food Systems and Their Impacts on Human Health, Food Security, and the Environment

The global food system is facing multiple problems, including rising food insecurity, degrading environments, and an increased incidence of diet-related chronic diseases. International organizations are thus calling for a transition toward territorialized food systems to alleviate some of these challenges. Yet, limited evidence supporting the benefits of territorialized food systems is available. Our objective was to summarize the current body of literature on territorialized food systems and their impacts on human health, food security, and the environment using a rapid review methodology. Articles were retrieved from three databases and analyzed using keywords and inclusion criteria corresponding to territorialized food systems, environment, human health, and food security. Six relevant publications were identified. While this limited evidence suggests that territorialized food systems may have positive effects on all three dimensions, data are not consistent across publications. For example, territorialized food systems may contribute to improved diet quality, provide agroecosystem services, and contribute to food security. However, food produced within these food systems may have a higher carbon footprint and be less available than industrially produced food. This rapid review also highlights the siloed nature of the current research on territorialized food systems and emphasizes the need for more holistic and interdisciplinary research.

Between- and within-Group Differences in Fruit and Vegetable Purchases, Consumption, and BMI among Hispanic Farmers' Market Shoppers Who Use SNAP

(1) Background: Despite considerable efforts to increase farmers' market access (FM) and improve household fruit and vegetable (FV) purchasing in low-income communities, little is known about the FV purchasing and consumption characteristics of low-income Hispanic farmers' market shoppers. (2) Methods: A secondary analysis of baseline data from a farmers' market study conducted between 2015 and 2017 (n = 2825) was performed. Participants who also received supplemental nutrition assistance program (SNAP) completed a 31-item online survey assessing demographics, health characteristics, and FV purchasing and consumption habits. Descriptive statistics and bivariate analyses were used to assess between- and within-group differences amongst Hispanic and non-Hispanic households. Regression analyses were used to examine associations among BMI, FV purchasing and consumption, and household size for Hispanic and non-Hispanic households as well as for Hispanic subgroups. (3) Results: The sample included 515 Hispanic and 2310 non-Hispanic SNAP-using FM shoppers in 13 states. Despite experiencing significantly higher food insecurity (89% vs. 81%, non-Hispanic), Hispanic shoppers consumed similar amounts of FV (3.04 cups/day) and spent less doing so. Significant subgroup differences were identified for FV purchasing. (4) Conclusions: Findings emphasize the importance of food insecurity and household size in FV interventions and underscore the capacity of Hispanic families to maintain FV consumption.

Qualitative Study on Participant Perceptions of a Supermarket Fruit and Vegetable Incentive Program

BACKGROUND

Complete Eats Rx is a fruit and vegetable prescription program designed to incentivize fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) participants via $10 incentives distributed either weekly or per encounter to purchase fruits and vegetables at a mid-price supermarket chain in Washington State.

OBJECTIVE

To better understand SNAP participants' experience, and to determine perceived impacts and consequences of the program.

DESIGN

Qualitative analysis of nine photovoice sessions. Participants chose the topics for discussion. Sessions were audiorecorded and transcribed. Thematic content analysis was performed to identify key emergent themes using Atlas.ti.

SETTING

Spokane, Seattle, and Yakima, Washington.

PARTICIPANTS

Twenty-six individuals who received a fruit and vegetable prescription within the past 6 months, 23 of whom attended all three photovoice sessions offered at their site. Participants were recruited from three participating health care or public health organizations in Spokane, Seattle, and Yakima, Washington.

ANALYSIS

Transcriptions were coded using inductive methods. Coded statements were organized into major themes. Coding structures and analysis were strengthened by iterative interactions between researchers.

RESULTS

Participants reported Complete Eats Rx was an important resource for families and improved food security, diet quality, and the ability to purchase healthy foods, including a greater variety of fruits and vegetables. Primary barriers to food security and fruit and vegetable consumption included limited geographic accessibility and the high cost of fruits and vegetables, exacerbated by other financial constraints such as rising housing costs. Participants reported supermarket checkout difficulty because of embarrassment, stigmatization, and inability to redeem incentives. The most frequently mentioned barrier to perceived program acceptability was having only one supermarket chain as the acceptor of the incentive.

CONCLUSION

Partnering with supermarkets to accept fruit and vegetable incentives is a unique strategy to increase produce purchasing that can be adopted by other localities. Focus on geographic accessibility, appropriate price points, and positive shopping experiences via expansion to local grocers, improvements in staff interactions, and a transition to an electronic system may improve incentive redemption and usability.

Higher Fruit and Vegetable Intake Is Associated with Participation in the Double Up Food Bucks (DUFB) Program

Incentivizing fruit and vegetable (F&V) purchases may help address barriers to healthy eating among populations with low income. In a repeated measures natural experiment study, we examined whether participation in the Double Up Food Bucks (DUFB) program increased F&V consumption among Supplemental Nutrition Assistance Program (SNAP) recipients. Two hundred and twelve participants recruited at baseline through telephone calls were informed about the availability of DUFB at their local farmers’ market (FM). F&V consumption frequency and DUFB use were obtained at baseline, mid FM, and end of FM season approximately 5 months later. Participants (N = 212) were primarily white (76.4%) women (77.3%) with an average age of 43.5 years. Only 34 participants opted to use the DUFB program. A linear mixed model showed a significant main effect of DUFB use (p = 0.001) and of time (p = 0.002), with a decrease in F&V intake over time. Compared to non-users, DUFB users had a significantly higher F&V consumption at baseline and midpoint (p = 0.02 and p = 0.02, respectively). F&V consumption was associated with participation in the DUFB program and higher F&V consumption frequency was observed prior to program use among program participants. Future interventions that specifically target SNAP recipients with low F&V intake to use the DUFB program are needed.

"I was eating more fruits and veggies than I have in years": a mixed methods evaluation of a fresh food prescription intervention

Background

Food insecurity is associated with poor nutritional health outcomes. Prescribing fresh fruits and vegetables in healthcare settings may be an opportunity to link patients with community supports to promote healthy diets and improve food security. This mixed methods study evaluated the impacts of a fresh food prescription pilot program.

Methods

The study took place at two Community Health Centre locations in Guelph, Ontario, Canada. Sixty food insecure patients with ≥1 cardio-metabolic condition or micronutrient deficiency participated in the intervention. Participants were prescribed 12 weekly vouchers to Community Food Markets. We conducted a one-group pre-post mixed-methods evaluation to assess changes in fruit and vegetable intake, self-reported health, food security, and perceived food environments. Surveys were conducted at baseline and follow-up and semi-structured interviews with participants were conducted following the intervention.

Results

Food security and fruit and vegetable consumption improved following the intervention. Food security scores increased by 1.6 points, on average (p < 0.001). Consumption of fruits and 'other' vegetables (cucumber, celery, cabbage, cauliflower, squashes, and vegetable juice) increased from baseline to follow-up (p < 0.05). No changes in self-reported physical or mental health were observed. Qualitative data suggested that the intervention benefited the availability, accessibility, affordability, acceptability, and accommodation of healthy foods for participating households.

Conclusions

Fresh food prescription programs may be a useful model for healthcare providers to improve patients' food environments, healthy food consumption, and food security.

Process Evaluation of a Farm-to-WIC Intervention

BACKGROUND

Despite the promise of farm-to-institution interventions for addressing limited vegetable access as a barrier to intake, programs designed for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are lacking. As such, little is known about the implementation of, and mechanisms of action through which, farm-to-WIC interventions affect vegetable intake and participant satisfaction with such programs.

OBJECTIVE

To examine whether a farm-to-WIC intervention to promote vegetable intake was implemented as intended, differences between participants who received the intervention relative to those in a usual-care control group in intermediate outcomes of vegetable-related knowledge, attitudes, and behaviors, and secondary outcomes of physical activity and weight status; and participant satisfaction with the intervention.

DESIGN

A process evaluation encompassing descriptive and comparative analyses of implementation fidelity logs and survey data collected as part of a pilot study was conducted.

PARTICIPANTS/SETTING

The setting was a large, New Jersey-based, urban WIC agency. Recruited between June 3 and August 1, 2019 through 3 of the agency's 17 sites (1 intervention and 2 control sites), participants were 297 primarily Hispanic adults (160 enrolled at the intervention site and 137 at control sites).

INTERVENTION

The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support, and recipe demonstrations and tastings.

MAIN OUTCOME MEASURES

Primary outcomes were vegetable intake (measured via self-report and objectively using dermal carotenoids as a biomarker of intake) and the redemption of vouchers provided by WIC for fruit and vegetable purchases at farmers' markets (measured objectively using data provided by WIC). For the process evaluation, logs were used to document program activities. Vegetable-related knowledge, attitudes, and behaviors, physical activity, and satisfaction with the intervention were assessed with participant questionnaires. Weight status was assessed with direct measures of height and weight. Data were collected at baseline and at mid- and post-intervention (3 and 6 months post-baseline, respectively).

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were used to characterize implementation fidelity. Associations between intermediate and secondary outcomes and vegetable intake were examined at baseline with Pearson correlations. Post-baseline between-group differences in the outcomes were examined with linear mixed-effects models adjusted for baseline values and covariates. Satisfaction with the intervention was assessed with inferential and thematic analyses.

RESULTS

Post-intervention, measures of vegetable intake were higher in the intervention relative to the control study group. Receipt of the intervention was also associated with a greater likelihood of voucher redemption. Nearly all participants (≥94%) received the intervention as intended at the WIC-based farmers' market; smaller percentages completed 1 or more planned trips to the area farmers' market (28%) and telephone coaching and support calls (88%). Although most intermediate and secondary outcomes were associated with measures of vegetable intake at baseline, the variables did not differ between study groups post-intervention. Mean satisfaction ratings were ≥6.8 on a 7-point scale. Recipe demonstrations, learning about vegetables, field trips, and the rapport with staff were liked most about the program. Although adding days and times for field trips was suggested, limited market days and hours of operation limited the ability to do so.

CONCLUSIONS

Preliminary data highlight the promise of this well-received intervention. Intermediate outcome findings suggest that other potential intervention mechanisms of action should be considered in future large-scale trials of this program. Broad-scale initiatives are needed to improve access to farmers' markets in underserved communities.

Citizen Scientist: Farm 2 Facts Supporting Farmers Markets

As multifunctional loci of local food economies and public activity, farmers markets impart diverse impacts on their surrounding communities. In response to the emerging scholarship on farmers markets, as well as the desires of market managers to buttress their decision-making with cogent data analysis, the Farm 2 Facts data collection toolkit was created by the University of Wisconsin-Madison to measure the economic, social, and ecological impacts of farmers markets. We document here the history of Farm 2 Facts. Through case studies of F2F members, we describe the ways in which individual markets, market organizations, and local governments use farmers markets as a means of achieving differing goals, as well as how Farm 2 Facts necessarily adapted to measure and support these goals. We argue that Farm 2 Facts is in a tight reciprocal relationship with market managers who become citizen scientists in order to support their managerial role and communicate the benefits of their markets. Given that market policy change is often the impetus for collecting data, empathy for the goals of market managers is inseparable from Farm 2 Facts. We find that a sensitivity to the dynamic needs of markets, an adaptive toolkit, and incorporating ongoing research into the toolkit are essential to supporting farmers market managers in their many duties.

Impact of Food Insecurity Nutrition Incentives on Household Fruit and Vegetable Expenditures

OBJECTIVE

Evaluate the impact of the Food Insecurity Nutrition Incentive (FINI) grant program on self-reported fruit and vegetable (FV) expenditures.

DESIGN

Pre-post quasi-experimental study design.

SETTING

Farmers markets and grocery stores in states with FINI projects.

PARTICIPANTS

A total of 2,471 Supplemental Nutrition Assistance Program (SNAP) households in 4 intervention groups who lived near a FINI retailer (farmers market or grocery store) and 4 matched comparison groups who did not live near a FINI retailer.

MAIN OUTCOME MEASURES

Awareness and use of point-of-sale incentives and changes in self-reported monthly household FV expenditures.

ANALYSIS

Ordinary least squares intent-to-treat regression model using lagged dependent variable model framework.

RESULTS

Awareness of FINI was higher among households who were near a FINI retailer and had shopped there before FINI than those who lived near a FINI retailer but had not shopped there before FINI; the number of information sources from which SNAP participants heard about FINI was positively associated with incentive receipt (P < 0.05). Among those who received incentives, the average amount of incentives received at the last shopping trip ranged from $15 to $23. The FINI program had a positive impact on the average monthly FV expenditures for those in the farmers market shopper, grocery store shopper, and grocery store general intervention groups-increases ranged from $9 to $15 (P < 0.05).

CONCLUSIONS AND IMPLICATIONS

Point-of-sale incentives were associated with an increase in FV expenditures among SNAP households. Further research is needed to examine (1) effective messaging strategies to increase incentive awareness and (2) the long-term impact of incentives on FV expenditures.

The Economic, Social, and Environmental Impacts of Farmers Markets: Recent Evidence from the US

Farmers markets are regular, recurring gatherings at a common facility or area where farmers and ranchers directly sell a variety of fresh fruits, vegetables, and other locally grown farm products to consumers. Markets rebuild and maintain local and regional food systems, leading to an outsized impact on the food system relative to their share of produce sales. Previous research has demonstrated the multifaceted impacts that farmers markets have on the communities, particularly economically. Recent scholarship in the United States has expanded inquiry into social impacts that markets have on communities, including improving access to fresh food products and increasing awareness of the sustainable agricultural practices adopted by producers, as well developing tools for producers and market stakeholders to measure their impact on both producers and communities. This paper reviews the recent scholarship on farmers markets to identify recent trends and synthesizes the current evidence describing the ways in which farmers markets contribute to the wellbeing of their communities, as well as identifying areas for additional future research.

Identifying Barriers to and Facilitators of Using a Mobile Fruit and Vegetable Market Intervention Delivered to Low-Income Housing Sites: A Concept Mapping Study

BACKGROUND

Mobile fruit and vegetable (F&V) markets may be a promising strategy to improve F&V intake among low-income and racial/ethnic minority groups. However, challenges remain in terms of maximizing the reach and utilization of such markets. Therefore, this study identifies perceived barriers to and facilitators of utilizing a mobile F&V market among residents who lived in low-income housing that received the markets. Specifically, this article reports the results of the follow-up acceptability study of the "Live Well, Viva Bien" (LWVB) intervention.

METHOD

We conducted concept mapping with residents in housing communities that received the Fresh to You (FTY) markets. Participants generated, sorted, and rated statements concerning barriers to and facilitators of market use. We compared the rating data by residents' level of market utilization and created a map representing how statements clustered into conceptual themes.

RESULTS

We retained 66 unique participant-generated statements. Eight thematic clusters emerged; four pertained to barriers: financial/promotion, produce-related, scheduling/knowledge, and logistic/awareness barriers, and four related to facilitators: produce/staffing, promotion, accessibility, and multilevel market facilitators. There was a strong correlation in ratings between participants who more frequently versus less frequently shopped at the markets (r = 0.94).

CONCLUSIONS

Participants identified financial barriers, market promotion, ease of market accessibility, produce variety and quality, and staffing as key factors influencing FTY market use. This study highlights the importance of identifying the perceived barriers to and facilitators of mobile F&V market use among target populations to inform future efforts to scale up such approaches.

Farmers Market Food Navigator Program: Key Stakeholder Perceptions and Program Outcomes

The Farmers Market (FM) Food Navigator program was designed over 3 years and follows a social ecological framework to increase vulnerable populations' access to local foods and build confidence to shop in a FM supporting local food systems while promoting fruit and vegetable consumption. Food Navigators followed a program Playbook, though unlike many similar programs, the program did not offer incentives to subsidize FM purchases. To inform program design and understand outcomes, data were collected from Food Navigators, shoppers, FM managers, and FM vendors. Food Navigators supported five to seven FMs each season (May through October), spending 590 days in FMs over three seasons. Due to their interaction with Food Navigators, shoppers in Season 3 (n = 689) indicated that they would: shop more at the FM (80%); eat more vegetables (52%); and purchase more vegetables (50%). Of shoppers who interacted with Food Navigators more than once (n = 55), 26% reported a higher frequency of vegetable consumption on their last survey compared with their first. In Season 3, at least half of FM managers (n = 4, 50%) and vendors (n = 68, 57%) agreed that food navigators helped increase overall market fruit and vegetables sales. Findings indicated the program did influence multiple levels of a social ecological framework as intended. FM nutrition programs can have success at increasing market sales and improving health-related behaviors without offering incentives. As a result, programs could operate with smaller budgets and be more likely to have increased shopper fruit and vegetable consumption sustainably beyond the direct subsidy of purchases.

A Multi Theory-Based Investigation of College Students' Underlying Beliefs About Local Food Consumption

OBJECTIVE

To identify college students' perceptions of local food on the basis of a multi-theory model.

DESIGN

Semistructured individual interviews were conducted. The Theory of Planned Behavior and Health Belief Model extended with self-congruity were used as a framework.

SETTING

A university in the southeast region of the US.

PARTICIPANTS

A total of 30 college students, including in-state, out-of-state, and international.

MAIN OUTCOME MEASURES

Behavioral beliefs, normative beliefs, control beliefs, perceived threats, self-congruity, cues to action, and definitions regarding local food.

ANALYSIS

Interviews were audio-recorded and transcribed verbatim. A hybrid inductive and deductive content analysis was used to analyze transcriptions.

RESULTS

Health benefits, supporting local, less processing, freshness, and trustworthiness were identified as advantages of consuming local food. Perceived disadvantages included limited variety and higher prices. Major themes related to normative beliefs included approval of family members and friends. Perceived barriers included lack of information, lack of availability, and inconvenience. Perceived facilitators included availability and clear advertisement. Poor dietary quality was a major threat. Local food consumers were identified as health conscious. Potentially effective cues to action were also identified. Emotion emerged as a new theme.

CONCLUSIONS AND IMPLICATIONS

The identified themes could be further explored for promotion of local food consumption among this population.

A dietary assessment tool to estimate arsenic and cadmium exposures from locally grown foods

Certain food products have been shown to accumulate arsenic (As) and cadmium (Cd) making it critical to monitor individual's intake, particularly when they live near sources of environmental contamination. After a literature review, a novel dietary assessment was conducted to estimate a child's potential exposure to these metal(loid)s via consumption of locally grown foods in communities impacted by active or legacy resource extraction activities. Mean ingestion rates of As- and Cd-translocating crops belonging to the Asteraceae, Brassicaceae, Caricaceae, Amaranthaceae, Cucurbitaceae, Liliaceae, Solanaceae, Apiaceae, and Fabaceae plant families were calculated for children: 1 to < 2 years, 2 to < 3 years, and 3 to < 6 years of age. These calculated ingestion rates ranged from 0 to 143,571 mg day^-1. Farmer-consumer relationship was the leading motivation for buying locally grown foods, while lack of experience/unfamiliarity was the most frequently reported reason for not buying locally. The median percentages of child's yearly consumption of fruits and vegetables originating from stores (conventionally grown) and from local sources (farmer's market) were 48% and 38%, respectively. Tomato was the crop with the highest intake rate among children 1 to < 2 years and 2 to < 3 years of age and broccoli for children 3 to < 6 years of age. It was concluded that families who are reliant on locally grown food products may be disproportionately exposed to As and Cd, which could cause detrimental health effects.

A Qualitative Evaluation of Double Up Food Bucks Farmers' Market Incentive Program Access

OBJECTIVE

Explore factors affecting access to and use of Double Up Food Bucks (DUFB), a farmers' market program that doubles Supplemental Nutrition Assistance Program benefits for use toward the purchase of fruits and vegetables (FV).

DESIGN

Focus groups.

SETTING

Metro and nonmetro counties in Utah and western Upstate New York.

PARTICIPANTS

Nine groups composed of 62 low-income adults (3-9/group).

PHENOMENA OF INTEREST

Satisfaction with, barriers to, and facilitators of program use; suggestions for improvement.

ANALYSIS

Transcribed verbatim and coded thematically in NVivo 11 software according to template analysis.

RESULTS

Program satisfaction was high and driven by FV affordability, perceived support of local farmers, positive market experiences, and high-quality FV. Primary barriers to using DUFB were lack of program information and inconvenient accessibility. Insufficient program communication was a consistent problem that elicited numerous suggestions regarding expansion of program marketing. Emergent topics included issues related to the token-based administration of DUFB and debate regarding stigma experienced during DUFB participation.

CONCLUSIONS AND IMPLICATIONS

Results suggest that although DUFB elicits many points of satisfaction among users, program reach may be limited owing to insufficient program marketing. Even among satisfied users, discussion of barriers was extensive, indicating that program reach and impact may be bolstered by efforts to improve program accessibility.

Identifying and assessing factors affecting farmers' markets Electronic Benefit Transfer sales in Hawai'i

OBJECTIVE

Electronic Benefit Transfer (EBT) placement at farmers' markets can reduce access disparities for low-income consumers. However, resources needed to operate EBT programs may challenge markets' business models. A conceptual model of factors impacting EBT program success was developed from literature, and an exploratory study conducted to assess the impact of model variables on market EBT sales.

DESIGN

Annual EBT sales data were obtained for all Hawai'i farmers' markets with EBT programs (n 22). Key informant interviews (n 19), along with records review, were performed to gather data on model variables. Exploratory analysis was conducted to estimate the impact of individual model variables on EBT sales.

SETTING

Farmers' markets accepting EBT in the state of Hawai'i.

PARTICIPANTS

Market managers and EBT program partners (n 19).

RESULTS

Markets engaging in community partnerships $\left( {{\mkern 1mu} {\mkern 1mu} \Delta \overline x = \$ 852} \right)$, consumer education $\left( {{\mkern 1mu} {\mkern 1mu} \Delta \overline x = \$ {\rm{598}}} \right)$, social media promotion $\left( {{\mkern 1mu} {\mkern 1mu} \Delta \overline x = \$ {\rm{732}}} \right)$ or EBT incentives $\left( {{\mkern 1mu} {\mkern 1mu} \Delta \overline x = \$ {\rm{5}}0{\rm{9}}} \right)$ averaged higher sales than markets not reporting these practices. Sales increased by $3 for every ten additional SNAP-participating households and decreased by $35 for each competing EBT-accepting supermarket, grocery or farmers' market within the market's access area. Sales increased by $137/vendor for each additional hour/week the market was open.

CONCLUSION

Factors suggested by the model, particularly community engagement and partnership, marketing methods, consumer base and competition for EBT sales in the market area substantively affected EBT sales. Assessing these factors may identify markets with the greatest chance of EBT success and suggest ways to strengthen struggling EBT programs.

Examining Shopping Patterns, Use of Food-Related Resources, and Proposed Solutions to Improve Healthy Food Access Among Food Insecure and Food Secure Eastern North Carolina Residents

In the Southern United States (U.S.), food insecurity rates are higher in rural (20.8%) versus urban communities (15%). Food insecurity can exacerbate diet-related disease. Thus, the purpose of this study was to examine differences in the use of food-related community resources and potential solutions proposed among food insecure versus food secure residents. A community survey (n = 370) was conducted in rural eastern North Carolina, with questions pertaining to food security status and food-related resources. The IBM SPSS Statistics software and SAS software were used to examine differences in food-related resources, and qualitative data analysis was used to examine differences in solutions offered between food insecure and food secure participants. Of the 370 respondents, forty-eight-point-six percent were classified as food insecure. Food insecure participants were more likely to report shopping for groceries at a convenience/discount store, less likely to use their own vehicle for transportation, and less likely to purchase food from local producers. Food insecure participants were more likely to suggest solutions related to reducing the cost of healthy food, while food secure participants were more likely to suggest educational or convenience-related interventions.

Impact of a farmers' market nutrition coupon programme on diet quality and psychosocial well-being among low-income adults: protocol for a randomised controlled trial and a longitudinal qualitative investigation

INTRODUCTION

Low-income populations have poorer diet quality and lower psychosocial well-being than their higher-income counterparts. These inequities increase the burden of chronic disease in low-income populations. Farmers' market subsidies may improve diet quality and psychosocial well-being among low-income populations. In Canada, the British Columbia (BC) Farmers' Market Nutrition Coupon Programme (FMNCP) aims to improve dietary patterns and health among low-income participants by providing coupons to purchase healthy foods from farmers' markets. This study will assess the impact of the BC FMNCP on the diet quality and psychosocial well-being of low-income adults and explore mechanisms of programme impacts.

METHODS AND ANALYSIS

In a parallel group randomised controlled trial, low-income adults will be randomised to an FMNCP intervention (n=132) or a no-intervention control group (n=132). The FMNCP group will receive 16 coupon sheets valued at CAD$21/sheet over 10-15 weeks to purchase fruits, vegetables, dairy, meat/poultry/fish, eggs, nuts and herbs at farmers' markets and will be invited to participate in nutrition skill-building activities. Overall diet quality (primary outcome), diet quality subscores, mental well-being, sense of community, food insecurity and malnutrition risk (secondary outcomes) will be assessed at baseline, immediately post-intervention and 16 weeks post-intervention. Dietary intake will be assessed using the Automated Self-Administered 24-hour Dietary Recall. Diet quality will be calculated using the Healthy Eating Index-2015. Repeated measures mixed-effect regression will assess differences in outcomes between groups from baseline to 16 weeks post-intervention. Furthermore, 25-30 participants will partake in semi-structured interviews during and 5 weeks after programme completion to explore participants' experiences with and perceived outcomes from the programme.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary Conjoint Health Research Ethics Board, Rutgers University Ethics and Compliance, and University of Waterloo Office of Research Ethics. Findings will be disseminated through policy briefs, conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03952338.

The Multiplier Effects of Food Relocalization: A Systematic Review

Background: The purchase of local food is often argued to stimulate local economies through multiplier effects; this argument is questioned in this paper. Methods: The ScienceDirect, Wiley Online Library, Taylor and Francis Online, SpringerLink, AgECON, and Emerald databases were searched systematically. A complementary search in Google Scholar was also carried out. Peer-reviewed studies published between 2000 and 2019 were identified using multiple search terms. Data about four types of multipliers (output, employment, income, and value-added multipliers) were extracted. Results: Twenty-four papers fit the criteria, allowing for a qualitative assessment only. Sixteen papers found unambiguously that an increase in demand for local food had a directly positive impact on local economies in some way; one paper found no impact at all. The papers were classified into three groups based on their focal areas: marketing channel-focused, farm enterprise-focused, and scenario/impact analysis-focused studies. In terms of the methods of analysis, three major approaches were identified: input–output models, assessments of descriptive statistics, and econometric analyses. Considerations related to the potential overestimation of current approaches are presented. Conclusions: The existence of employment and income multipliers seems to be more evident, while the impacts of output- and value-added multipliers depend more on the actual context. Research gaps are also identified.

"The coupons and stuff just made it possible": economic constraints and patient experiences of a produce prescription program

Although produce prescription (PRx) programs have been shown to improve fruit and vegetable (FV) consumption, few studies have examined how economic constraints influence participant experience. We conducted a qualitative study of patient experience of a 3-month PRx program for hypertension (PRxHTN) including 3 safety-net clinics and 20 farmers' markets (FMs). We interviewed 23 PRxHTN participants using semistructured guides to understand their program experiences. Interviews were audio-taped, transcribed, and analyzed to identify a priori and emergent themes. PRxHTN participants completing qualitative interviews were mostly middle-aged (mean: 62 years) African American (100%) women (78%). Economic hardship as a barrier to maximum program participation and sustainability was a main theme identified, with three subthemes: (i) transportation issues shaped shopping and eating patterns and limited participant ability to access FMs to utilize PRxHTN vouchers; (ii) limited and unstable income shaped participant shopping and eating behavior before, during, and after PRxHTN; and (iii) participants emphasized individual-level influences like personal or perceived motivations for program participation, despite significant structural constraints, such as economic hardship, shaping their program engagement. Future PRx programs should bolster economic and institutional supports beyond FM vouchers such as transportation assistance, partnering with local food banks and expansion to local grocery stores offering year-round FV access to support sustained behavior change. Additionally, structural competency tools for providers may be warranted to reorient focus on structural influences on program engagement and away from potentially stigmatizing individual-level explanations for program success. These efforts have potential to enhance the translation of PRx programs to the needs of economically vulnerable patients who struggle to manage chronic illness and access basic nutrition.

The Development of Straw-Based Biomass Power Generation in Rural Area in Northeast China—An Institutional Analysis Grounded in a Risk Management Perspective

Given a lack of consideration for the role and importance of stakeholders and the importance of stakeholders in the operation of biomass power plants in China, a comprehensive analysis oriented toward stakeholder risk management is needed to further develop the country’s biomass energy industry. Accordingly, we analyzed institutional factors that contribute to or constrain progress in biomass power generation in China. Data were collected from 275 straw suppliers (farmers) living around a biomass power plant, 15 middlemen, five power plant managers, and five local government officers. Interviews were held with all the participants, but questionnaires were additionally administered to the straw suppliers. Results showed that: (1) risk transfer in the biomass supply chain is one of the reasons why farmers are unwilling to supply straw; (2) middlemen are vital intermediaries between biomass power plant managers and farmers as a middleman-based biomass supply system is necessary to guarantee the quantity of straw supply, and; (3) the institutional structure that underlies the Chinese biomass energy industry is immature.

Racial/Ethnic Differences in the Shopping Behaviors and Fruit and Vegetable Consumption of Farmers' Market Incentive Program Users in Illinois

Introduction

Farmers' market incentive programs, such as Link Match, provide monetary incentives to Supplemental Nutrition Assistance Program (SNAP) participants to promote their use of local farmers' markets. Information on racial/ethnic differences in the shopping behaviors and fruit and vegetable (FV) consumption of farmers' market incentive program users is scarce. This research aimed to address this need by examining users of the Link Match incentive program in Illinois.

Methods

A cross-sectional survey of 328 Link Match users (39.6% non-Hispanic White; 45.4% non-Hispanic Black; and 15.0% other) was conducted in 2016 and 2017. Information on each participant's demographics, farmers' market shopping behaviors, and monthly frequency of FV consumption was collected from Link Match users. Chi-square and ANOVA tests were used to assess differences in farmers' market shopping measures by race/ethnicity. Logistic regression models were used to examine the association between race/ethnicity and frequency of FV consumption.

Results

A significantly higher percentage of non-Hispanic Black participants reported being an infrequent farmers' market user (ie, shopping ≤ once a month) compared with non-Hispanic White and other participants (P=.01). After adjusting for covariates, non-Hispanic Black participants had lower odds of consuming fruit daily (OR: .44; 95% CI:.22-.86) compared with non-Hispanic White participants. Other participants had lower odds of consuming both fruit and vegetables compared with non-Hispanic White participants (OR: .30; 95% CI:.12-.71).

Conclusions

Differences in shopping behaviors and FV consumption were observed by race/ethnicity among Link Match users. Future research should examine the nutritional implications of these differences.

Fruit and Vegetable Purchases in Farmer's Market Stands: Analysing Survey and Sales Data

Farmers' market implementation holds promise for increasing access to healthy foods. Although rarely measured, purchase data constitute an intermediate outcome between food environment and actual consumption. In a study conducted with two seasonal Fruits and Vegetables (FV) stands in a disadvantaged area of Montréal (Canada), we analysed how accessibility, perception, and mobility-related factors were associated with FV purchase. This analysis uses a novel measure of FV purchasing practices based on sales data obtained from a mobile application. A 2016 survey collected information on markets' physical access, perceived access to FV in the neighbourhood, usual FV consumption and purchases. Multivariate models were used to analyse three purchasing practice indicators: number of FV portions, FV variety and expenditures. Average shoppers purchased 12 FV portions of three distinct varieties and spent 5$. Shoppers stopping at the market on their usual travel route spent less (p = 0.11), bought fewer portions (p = 0.03) and a lesser FV variety (p < 0.01). FV stands may complement FV dietary intake. Individuals for whom the market is on their usual travel route might make more frequent visits and, therefore, smaller purchases. The novel data collection method allowed analysis of multiple purchase variables, is precise and easy to apply at unconventional points of sales and could be transposed elsewhere.

"You Guys Really Care About Me…": a Qualitative Exploration of a Produce Prescription Program in Safety Net Clinics

BACKGROUND

Although research shows produce prescription (PRx) programs increase fruit and vegetable (FV) consumption, little is known about how participants experience them.

OBJECTIVE

To better understand how participants experience a PRx program for hypertensive adults at 3 safety net clinics partnered with 20 farmers' markets (FMs) in Cleveland, OH.

DESIGN

We conducted semi-structured interviews with 5 program providers, 23 patient participants, and 2 FM managers.

PARTICIPANTS

Patients interviewed were mainly middle-aged (mean age 62 years), African American (100%), and women (78%). Providers were mainly middle-aged men and women of diverse races/ethnicities.

INTERVENTION

Healthcare providers enrolled adult patients who were food insecure and diagnosed with hypertension. Participating patients attended monthly clinic visits for 3 months. Each visit included a blood pressure (BP) check, dietary counseling for BP control, a produce prescription, and produce vouchers redeemable at local FMs.

APPROACH

Patient interviews focused on (1) beliefs about food, healthy eating, and FMs; (2) clinic-based program experiences; and (3) FM experiences. Provider and market manager interviews focused on program provision. All interviews were audio-taped, transcribed, and analyzed thematically.

KEY RESULTS

We identified four central themes. First, providers and patients reported positive interactions during program activities, but providers struggled to integrate the program into their workflow. Second, patients reported greater FV intake and FM shopping during the program. Third, social interactions enhanced program experience. Fourth, economic hardships influenced patient shopping and eating patterns, yet these hardships were minimized in some participants' views of patient deservingness for program inclusion.

CONCLUSIONS

Our findings highlight promises and challenges of PRx programs for economically disadvantaged patients with a chronic condition. Patient participants reported improved interactions with providers, increased FV consumption, and incorporation of healthy eating into their social networks due to the program. Future efforts should focus on efficiently integrating PRx into clinic workflows, leveraging patient social networks, and including economic supports for maintenance of behavior change.

Harnessing Knowledge for Improving Access to Fruits and Vegetables at Farmers Markets: Interactive Data Visualization to Inform Food Security Programs and Policy

High consumption of fruits and vegetables leads to decreased risk of various chronic diseases, including obesity and cardiovascular disease. Community-level barriers to access fruits and vegetables include the high cost, limited availability, and transportation. Farmers markets are a priority strategy for improving community access to fresh fruits and vegetables. The U.S. Department of Agriculture (USDA) National Farmers Market Directory is a voluntary self-reported data source on farmers markets. The objective of this investigation of the USDA farmers markets data directory was to determine how farmers markets in the United States are grouped according to (1) availability of fruits and vegetables and (2) the payment accepted. We designed and implemented interactive data visualizations in visual analytics software to understand access to fruits and vegetables at farmers markets from 8,497 entries in the USDA Farmers Market Directory. Among the 665 new or updated entries in year 2018, a subset of 641 (96%) farmers markets with availability of fresh fruits and vegetables had 16 subgroups. Additionally, a subgroup of 102 (16%) farmer markets accepted all four federal nutrition assistance benefits (SFMNP, SNAP, WIC CVVs, and WIC FMNP). The interactive data visualizations including geographic maps connected to social media resources can be useful in advocacy efforts and can inform policy improvements designed to improve physical, social, and economic access to fruits and vegetables at farmers markets.

The role of food gateways at increasing access to alternative retail food outlets

“Food gateways”, or individuals providing transportation, food distribution, and advocacy, can improve access to alternative retail food outlets for vulnerable populations.

Adoption and Reach of a statewide policy, systems, and environment intervention to increase access to fresh fruits and vegetables in West Virginia

Local public health professionals’ consistency, connections, and presence at meetings were critical to making changes in schools, farmers markets, and retail food stores to improve access to fruits and vegetables in rural, low-income food deserts.

"Prevention Produce": Integrating Medical Student Mentorship into a Fruit and Vegetable Prescription Program for At-Risk Patients

INTRODUCTION

Fruit and vegetable prescription (FVRx) programs provide increased access to produce to food-insecure, at-risk populations, yet many lack the educational and social components to support long-term disease prevention.

OBJECTIVES

To address these barriers, students at Penn State College of Medicine designed "Prevention Produce"-a modified FVRx program that integrated a community-based, month-long educational curriculum-and undertook preliminary evaluation.

METHODS

Nine families deemed by clinicians as at risk of chronic disease and food insecurity received weekly $40 "prescriptions" for produce at partnering farmers markets. Participants were paired with medical student mentors who delivered weekly nutrition education modules and assisted in produce shopping. Preprogram and postprogram surveys were administered, categorizing perceptions and practices of healthy eating. All participants were interviewed by phone 3 years later to assess long-term impact. Medical students provided written reflections via online survey.

RESULTS

Postprogram fruit and vegetable consumption increased, and more patients expressed efforts to include produce in every meal. More participants strongly agreed that fruits and vegetables prevented chronic diseases. In reflective interviews, participants praised the program's ease of use, mentor-patient relationship, and increased access to produce. Student mentors expressed gratitude for one-on-one interaction and felt empowered to learn and deliver nutrition education.

CONCLUSION

Integration of an FVRx program with education, mentorship, and community-based focus may increase produce consumption and improve opinions about healthy eating. This program serves as a model for integrating preventive strategies within larger health care systems. Additionally, the model can facilitate early clinical interventions that may benefit medical trainees' professional development.

Manager Perspectives on Implementation of a Farmers' Market Incentive Program in Maryland

OBJECTIVE

A growing number of farmers' markets offer incentive programs to increase access to fresh produce in low-income communities and support local farmers, yet program implementation has not been widely studied. This qualitative study explored market manager perspectives on implementing a Maryland statewide farmers' market incentive program.

DESIGN

Semistructured interviews with market managers.

SETTING

Participating farmers' markets across Maryland.

PARTICIPANTS

Managers of participating farmers' markets (n = 19).

PHENOMENON OF INTEREST

Barriers and facilitators to program implementation and recommendations for improvement.

ANALYSIS

Interviews were analyzed using a phronetic iterative approach and themes were organized using an adapted version of a multilevel implementation framework.

RESULTS

Managers reported overall favorable attitudes toward the incentive program. They identified barriers to implementation such as vendor buy-in and funding uncertainties, facilitators such as private fund-raising and local champions, and opportunities for improvement such as strengthening promotion and increasing the use of technology to reduce the data collection burden.

CONCLUSIONS AND IMPLICATIONS

Managers identified implementation barriers (eg, customer confusion) and facilitators (eg, ease of staff training) that may be shared by other incentive programs. Based on these findings, barriers and recommendations may be addressed through collaborative problem-solving with managers, vendors, and customers, and facilitators can be amplified broadly. Future research is warranted to explore incentive program implementation in other settings.

Do young adults value sustainable diet practices? Continuity in values from adolescence to adulthood and linkages to dietary behaviour

OBJECTIVE

To describe continuity over time in reports of valuing sustainable diet practices and investigate relationships between values, household meal behaviours and dietary intake.

DESIGN

Observational study. Participant ratings of how important it is for food to be produced as organic, not processed, locally grown and not GM were categorized to represent whether they valued (very/somewhat important) or did not value (a little/not at all important) each practice. Diet quality markers (e.g. fruit servings) were based on an FFQ.

SETTING

Mailed and online surveys.

PARTICIPANTS

Young adults (n 1620; 58 % female, mean age 31 (sd 1·6) years) who were participating in Project EAT (Eating and Activity among Teens and Young Adults) and responded to follow-up surveys in 2003-2004 and 2015-2016.

RESULTS

One-third (36·1 %) of participants reported valuing <2 practices at both assessments; 11·1 and 34·5 % respectively reported valuing ≥2 practices in 2003-2004 only and in 2015-2016 only; 18·3 % reported valuing ≥2 practices at both assessments. Regression models including demographics, parental status and vegetarian status showed that valuing ≥2 practices was associated with preparation of meals with vegetables at least a few times/week, less frequent purchase of family meals from fast-food restaurants, and higher diet quality in 2015-2016. For example, those who valued ≥2 practices consumed nearly one full vegetable serving more than other young adults on an average day and part of this difference was specifically associated with intake of dark green and red/orange vegetables.

CONCLUSIONS

Addressing the sustainability of food choices as part of public health messaging may be relevant for many young adults.

Predictors of Supplemental Nutrition Assistance Program Use at Farmers' Markets With Monetary Incentive Programming

PURPOSE

Healthy food incentive program implementation targeting people receiving Supplemental Nutrition Assistance Program (SNAP) benefits is supported by the federal Food Insecurity Nutrition Incentive (FINI) grant program. This study examined factors contributing to increased SNAP use at farmers' markets with an FINI-funded incentive program.

DESIGN

Implementation evaluation.

SETTING

Sixteen states and District of Columbia.

PARTICIPANTS

Two hundred eighty-two FINI-funded farmers' markets open in 2016.

MEASURES

Weekly SNAP sales and transactions per 1000 SNAP households in the Zip Code Tabulation Areas around markets.

ANALYSIS

Two-level hierarchical regression modeling.

RESULTS

Most farmers' markets (53%) had less than 100 SNAP transactions in 2016. Weekly SNAP sales and transactions per 1000 SNAP households were 69.9% and 47.7% higher, respectively, if more than 1 incentive was available versus 1. Not having paid market staff resulted in declines in these sales (-34.3%) and transactions (-38.1%) compared to markets with paid staff. There was a 6.2% and 5.1% increase in SNAP sales and transactions for each additional produce vendor. Weekly SNAP sales and transactions were about 2 to 3 times higher in rural areas compared to metropolitan. Clustering of markets within states explained 10% of the variation in weekly SNAP sales and transactions.

CONCLUSION

Four implementation factors were identified that may facilitate the reach of SNAP-based monetary incentive programs at farmers' markets to maximize reach and impact among SNAP shoppers.

Farmers’ Market Actors, Dynamics, and Attributes: A Bibliometric Study

Farmers’ markets aim to bring producers and consumers together under direct marketing schemes, also known as alternative food networks, for local and sustainable production and consumption of food. A number of studies concerning this subject have been published, however, as yet no updated reviews exist that might allow us to understand the trends in research on farmers’ markets. The objective of this study was to examine the farmers’ market literature using bibliometric tools. A total of 438 peer-reviewed publications, indexed in the abstract and citation meta-database Scopus (Elsevier®), for the period of 1979 to September 24, 2018, were considered. In the second phase, publications in the area of medicine were excluded, resulting in 295 publications being analyzed for the same period. The results showed that these publications focused on three main areas: markets, health programs, and food safety. Upon exclusion of the medical publications, the remaining works focused on farmers’ market actors, dynamics, and attributes: vendors (producers and others), consumers, the community, and supporting actors and institutions (government, NGOs, individuals). Therefore, it is concluded that there is no single type of farmers’ market, nor of farmers’ market vendors or consumers. This makes the reproduction of such spaces difficult, especially when the goals are to benefit local production systems or the nutrition of the local community.

An Assessment of Perceived Barriers to Farmers' Market Access

OBJECTIVE

To explore whether Supplemental Nutrition Assistance Program-Education (SNAP-Ed) stakeholders (individuals involved in work to increase access to farmers' markets [FMs] for low-income populations) perceive the same barriers to shopping at FMs as those reported by SNAP participants in Washington State.

DESIGN

Descriptive study; data included a stratified clustered random sample of SNAP participants and stakeholder interviews.

SETTING

Washington State.

PARTICIPANTS

A total of 400 SNAP participants and 51 SNAP-Ed stakeholders.

MAIN OUTCOME MEASURES

The SNAP participants' reported barriers to accessing FMs and the SNAP-Ed stakeholders' perceptions of FM access barriers.

ANALYSIS

Thematic content analysis, descriptive statistics, 2-sample tests of proportion, and Pearson chi-square tests (P < .025).

RESULTS

A majority of SNAP participants reported they did not shop at an FM because it is inconvenient (n = 193; 51%) and not financially viable (n = 84; 22%). Moreover, 9% of SNAP participants (n = 34) stated that they experienced no barriers. The SNAP-Ed stakeholders placed increased emphasis on transportation and cost barriers compared with the SNAP participants.

CONCLUSIONS AND IMPLICATIONS

Comprehensive, multilevel strategies that reflect the perspectives of SNAP participants could increase SNAP use at FMs. Opening FMs in diverse locations at variable operating times may address convenience barriers while engaging the targeted populations' communities to promote FMs, and FM incentive programs may address financial and awareness barriers.