Which Food access strategies have the greatest potential for success?

1. Which Food access strategies have the greatest potential for success? Matching Preferences of Lower-Income Families with Stakeholder Resources Christina Kasprzak MS Principal Investigator: Lucia Leone PhD Department of Community Health and Health Behavior School of Public Health and Health Professions

2. Background and study aims

3. Goals of this Research • Understand the food access needs of lower-income families within Western New York communities • Describe the availability of food access programs available to lower-income individuals • Compare those needs to available resources

4. Why is This Research Important? • Lower-income individuals are disproportionately burdened by chronic diseases [Williams et al. 2010, Braveman et al. 2010] • These health disparities may be explained, in part, by poor diet[Satiaet al. 2009] • Underserved communities may be more susceptible due to food insecurity • USDA defines food insecurity as reports of “reduced quality, variety, or desirability of diet,” with or without reduced food intake

5. Why is This Research Important? • Mere physical proximity to healthy food is one of many factors that interplay to influence diet • There is a need to understand the nuances of food access and the specific barriers and facilitators to consuming a healthful diet • The CDC Healthy People 2010 review reported that the nation as a whole failed to meet the goal of 2 daily servings of fruit, and 3 daily servings of vegetables, although higher income groups fared better • This research builds on past qualitative research that has identified barriers and facilitators, mostly in more targeted populations • First qualitative research addressing facilitators and barriers to accessing healthy food within Western New York and how participants’ preference match stakeholders’ resources

6. Study Design and Analysis • 13 focus groups with 98 lower-income participants in urban communities of Western New York from July 2015 to April 2016 • 8 of the 13 focus groups were exclusively WIC participants at WIC offices • The remaining 5 were recruited by community partners serving lower-income families • 17 stakeholder interviews with grocery store owners, small farmers, and key informants from community organizations

7. Study Design and Analysis • Semi-structured, 2-hour focus groups moderated by the PI and project manager • Elicited discussion about barriers and facilitators to access healthy food, especially fruits and vegetables (F&Vs), and the types of programs that would be most helpful • Interviews with stakeholders focused on the types of programs they are currently implementing or would be interested in implementing to increases access to healthy food • Focus groups were transcribed and independently coded by 2 coders using qualitative software • Interviews were transcribed and summarized in memos

8. Focus group findings

9. Focus Group Participants • 98 participants attended 13 focus groups • Average age: 38 years • Average household size: 3 *Participants with an income bracket that spans the low-income cutoff point based on household size.

10. Community’s Biggest Health Concerns

11. Community’s Biggest Health Concerns “Diabetes, all my friends have diabetes. Almost all of them, and my family.” “The blood pressure, strokes and that does have something to do with the nutrition you eat, and how you eat. So I’m a prime example.” “Um, well, actually I think the food itself is different. When I came up there wasn’t so many things to worried about in the food that you were consuming. Nowadays, even if you do consume fresh fruits or vegetables or something that is supposed to be sustainable, now you got to go to – well what did they use in the process of growing it.”

12. Where Do Participants Shop? • Variety of places including chain supermarkets, Farmer’s Markets, grocery stores, supercenters, discount stores, and wholesale clubs • Choose to travel farther, often outside their neighborhood, to find the best quality and priced F&Vs • Rarely frequent fast food and restaurants for regular meals • Avoid shopping at corner stores unless necessary

13. Where Do Participants Shop? “Them [supermarkets] about the only places you can go get vegetables.” “You have to go to your local supermarket…as opposed to the corner store.”

14. Fruit and Vegetable Purchasing Priorities

15. Barriers To Healthy Food Consumption

16. Barriers To Healthy Food Consumption “I’ve been trying to eat more vegetables and fruit, but the cost of those things to keep them in the house is astronomical.” “Just everything is moving further and further out, and they’re forgetting about us. The ones that don’t have cars you know.”

17. Perceptions of Access to Healthy Food • Double the number of participants felt they lack access to healthy food than those who felt they have access • Stores considered easily accessible if within walking distance • Transportation impacts access, especially access to or possession of a vehicle • Other factors: public transportation, walkability, distance, physical mobility, safety, and weather • Recurrent theme: access to affordable, high-quality F&Vs requires travel

18. Perceptions of Access to Healthy Food • Nearby food retailers often do not sell F&Vs or were not acceptable quality or cost • The barrier of cost is experienced differently by participants based on where they shop and the season, but there was general consensus that F&Vs are too costly and their total food budget is insufficient • Awareness of price disparities between healthy and less healthy food: forced to make tradeoffs

19. Perceptions of Access to Healthy Food “It’s a little dangerous around to go to the store.” “See, there’s not a lot by my house. I mean, there’s a Tops and Walmart, but [within] close walking distance, no. There’s not anything around where I am.” “Because like I said, I don’t have transportation and when it’s wintertime…” “They feed to what community they have which is not fair.”

20. Other Barriers to Healthy Food Consumption • Limited SNAP eligibility and insufficient SNAP and WIC benefits “I went down there and I applied for food stamps and they told me [laughter] – they’re like, ‘You make one dollar too much.’” “Yeah, the working poor. You don’t qualify for those things.” “And then one time when they did give me food stamps, they gave me $10 a month. “ “And it’s so important to have enough that sometimes I don’t think $10 is enough.”

21. Other Barriers to Healthy Food Consumption • Distaste “My nine-year old won’t touch either one, fruit or vegetables.” “I don’t eat the broccoli, carrots, celery, none of that…I never have. My mother never um – I never have.”

22. Other Barriers to Healthy Food Consumption • Goes back quickly “They get old so fast.” “You think it’s fresh and then you bring it home and then it’s not so fresh.”

23. Facilitators To Healthy Food Consumption • Affordability • F&V vouchers - WIC and Seniors Farmers’ Market Nutrition Program (FMNP) • F&V incentive programs – Double Up Food Bucks (DUFB), health insurance • Recipeideas for preparing F&Vs

24. Facilitators To Healthy Food Consumption “Like if maybe um, they had us bring ideas to encourage them to eat more vegetables. That helps a lot, because I think we’re just out of ideas.” “It made me buy more fruit and vegetables because I know I’m getting half of that money back.”

25. Healthy Food Programming: Farmers’ Market Incentive Programs • Aware of voucher programs (WIC/Seniors FMNP), less aware of SNAP matching program (DUFB) • Positive feedback among those who have utilized programs • Interest among those who have not

26. Healthy Food Programming: Community Supported Agriculture • Novel concept to most • Concerns about cost, up front investment, and lack of choice • Appealing if quality was guaranteed and the cost could be offset or reduced • Programming ideas: home delivery model, installment payments, more choice over size and contents

27. Healthy Food Programming: Community Gardens • Most aware, but few involved in community gardens • Interested in theory, but in practice, felt there were too many barriers • Concerns about collaborate nature, time, knowledge, trust and safety • Alternative to community gardens: personal plots for community members • More education and focus on family involvement may increase interest and participation

28. Healthy Food Programming: Mobile Produce Markets • Minimal awareness and experience with mobile markets • Those that have shopped at mobile market spoke highly of the experience • Those that were unfamiliar were interested in the concept • Concerns included achieving trust with the community, weather, and short operating season • Programming ideas: cooking demonstrations, acceptance of Federal nutrition benefits, consistent presence, and extending the season

29. Healthy Food Programming: Healthy Corner Store Programming • Known locally as the Healthy Corner Store Initiative (HCSI) • Mixed awareness, limited participation • Although many shop at corner stores out of convenience, there were strong preferences to shop for F&Vs at other retailers • Concerns included safety, cleanliness, management that does not represent the community, trust, quality, and cost of F&Vs • Programming ideas: improve customer service, more oversight over F&V quality, improve the atmosphere, carry culturally relevant foods, and reduce F&V prices

30. Participant-generated Programming Ideas • Nutrition education classes that are family friendly and incorporate youth and schools • F&V home delivery model • Employer or government sponsored F&V incentive programs • Increase in benefits through Federal nutrition programs • Expansion of eligibility for Federal nutrition programs • Expanding SNAP matching programs (DUFB) to include those that demonstrate need but not on an assistance program - “the working poor”

31. Participant-generated Programming Ideas “If it’s attractive to the children, they’re gonna’ nag their parents to get them to do whatever is necessary” “Some kind of cooking class. I know some veggies are a little daunting and if, like, you know, there were some type of demonstration on some way to prepare them that was easy and delicious.”

32. Stakeholder interview findings

33. Stakeholder Interviews • Key informants: Representatives from a WIC office, hunger relief non-profit, community farm programs, and mobile produce markets • Small food retailers: three urban convenience stores (two locally owned and one corporate owned) • Large food retailers: grocery store, supermarket, and supercenter from first-tier suburbs • Four farmers: three in rural areas and one operating in the city • One food aggregator

34. Stakeholder Interviews: Key Informants • Similar missions of facilitating food and nutrition services, providing education, increasing food access, supporting the growth of an equitable food system • Barriers to access and consumption of healthy food among their clients: cost, lack of time, need for cooking skills and knowledge • Specific to barriers in accessing a Farmers’ Markets: lack of transportation, inconvenient locations and hours

35. Stakeholder Interviews: Key Informants • Strategies need to move beyond merely access and address knowledge, interest, and a disconnect from the food system – systems change vs individual change • Focused efforts on children and young mothers • Offer culturally appropriate goods and services • Stakeholders’ organizations offer services including: on-site and community based nutrition programming, cooking demonstrations and classes, youth leadership, farming and farming education, facilitation for enrollment on Federal nutrition assistance programs, and selling reduced cost produce in low-income communities • Programming ideas: agencies hosting mobile markets or CSA pick-up sites if farms offer reduced cost produce and accept SNAP/WIC/FMNP as payment

36. Stakeholder Interviews: Food Retailers • All serve the low-income population: range from 20-50% of customer base • All participate in the SNAP program, most in the WIC program • All retailers open and interested in expanding F&V varieties to meet customers’ needs • Corporate owned stores more beholden to corporate office, but some degree of autonomy in stocking choices • Larger retailers, such as grocery stores, have more control over inventory than smaller retailers

37. Stakeholder Interviews: Food Retailers • Locally owned, small retailers are interested in selling more F&Vs and committed to improving the community, meeting customers’ needs, and improving their reputation Demand among the community for more culturally relevant F&Vs Barriers: space, equipment, minimal profitability Support needs: sourcing, inventory, F&V handling, pricing, marketing “Very interested, a lot of people in houses eat a lot of junk, eat candy. People need something with less sugar, it’s very important for me to put more [produce].” “It's a good idea. It would promote the business for us too.”

38. Stakeholder Interviews: Farmers • Mostly sell to wholesalers, distributors, large retailers, and restaurants • All recognize the need and are open to more directly serving low-income customers • Would like to reconnect customers with where their food comes from • Some operate CSA programs and participate or are interested in participating in reduced cost shares, accepting SNAP, and incentive programs (FMNP, DUFB)

39. Stakeholder Interviews: Farmers • Piloting a cost-offset CSA share • Donating CSA shares to a mobile market and offering reduced cost shares that can be purchased with SNAP benefits • Programming ideas: urban CSA drop-off sites, selling to a network of urban corner stores at a reduced cost, donating wasted produce “A few boxes or a few cases or even a pallet at a lower cost is not going to affect the end payout typically…in the grand scheme of things, it probably wouldn’t affect me per se or my growers that much.” - Aggregator

40. Future directions

41. Conclusions • Findings align with mounting literature that a healthy dietary pattern, one that prioritizes F&Vs, costs more than less healthy options • Food access continues to be a very nuanced and contextual – much more than proximity • There are facilitators to accessing and consuming healthy food that match stakeholder resources

42. Conclusions • There are areas where we can focus on increasing understanding of resources available and raising awareness among low-income communities • Stakeholders understand the barriers that low-income populations face and want to be part of the solution • There is interest and capacity among stakeholders to facilitate access to affordable and quality healthy food among low-income communities • In some cases, there is a mismatch between community members perceptions and stakeholders’ motives

43. Where Do We Go From Here? • Connect participants with resources Nutrition educationand recipe ideas F&V incentive programs Reduced cost CSA shares • Connect stakeholders to stakeholders Farmers to small urban retailers Farmers to agencies that oversee Federal incentive programs Farmers and mobile markets to community partners

44. Where Do We Go From Here? • Increase understanding and awareness Shift perceptions of community members: corner stores, gardening Increase knowledge of CSA shares, mobile produce markets, F&V home delivery models, and incentive programs (DUFB) • Support stakeholders Provide guidance on sourcing, pricing, handling and marketing of fresh F&Vs to small retailers Create infrastructure or liaison between farmers and urban agencies that serve the low income community

45. Where Do We Go From Here? • Policy and advocacy work Regional and Federal incentive programs that are well designed Transportation options

46. Acknowledgements • Lucia Leone PhD Principal InvestigatorUniversity at Buffalo • Halle A. Sauer Research Assistant University at Buffalo • Julia J. Schoonover Research Assistant University at Buffalo • Margaret Lapp Project Manager University at Buffalo

47. Questions? CMK27@buffalo.edu