Abstract
Introduction:
Patient participation in healthcare system-sponsored efforts to address food insecurity varies widely. This mixed-methods study sought to understand patient sociodemographic factors associated with, and barriers and facilitators to, use of a monthly produce market held at Cambridge Health Alliance in partnership with The Greater Boston Food Bank.
Methods:
Baseline surveys (n=715) were conducted from February 2019–March 2020 prior to market attendance, followed by 1-year follow-up surveys (n=514) and qualitative interviews (n=45). Robust Poisson regression estimated associations between sociodemographic characteristics and market attendance. Analyses were conducted from 2021–2022.
Results:
37.1% attended the market ≥1 time. Market attendance was associated with being aged 30–49 years (RR=1.36, 95% CI=1.00, 1.86); having a monthly household income of <$1,000 (RR=1.73, 95% CI=1.29, 2.32); identifying as Asian (RR=2.48, 95% CI=1.58, 3.89); having a preferred language for medical care other than English (RR=1.35, 95% CI=1.03, 1.76); being retired (RR=1.90, 95% CI=1.17, 3.08); and living in the city of the market’s location (RR=1.36, 95% CI=1.12, 1.63). Barriers included limited time (28%), work conflict (23%), forgetfulness (23%), and not knowing market location/date (22%). Interviews revealed accessibility barriers (e.g., limited market hours, transportation issues, competing demands, medical conditions, long lines) were obstacles to attendance, while access to novel, healthy foods motivated attendance.
Conclusions:
Healthcare-based food distributions have the potential to reach patients with unmet food needs who cannot, or would not, access other forms of food assistance. Time constraints, physical limitations, and transportation challenges impact attendance; program modifications are necessary to improve accessibility.
INTRODUCTION
A growing recognition of the healthcare costs of food insecurity1 and a movement towards value-based care have prompted increased awareness by healthcare systems of unmet social needs, including food security.2 This has led to collaborations between healthcare systems and hunger-relief organizations that provide food assistance in healthcare settings.3 Food insecurity in the U.S., defined by the U.S. Department of Agriculture (USDA) as a household-level economic and social situation of limited or uncertain access to adequate food, impacted 10.5% of people (13.8 million households) in 2020.4 Due to the economic impact of the COVID-19 pandemic, in 2020, food insecurity increased disproportionately among households with children and non-Hispanic Black and Latino households.4–7 Food insecurity may be mitigated by healthcare systems implementing evidence-based food access interventions.8,9 These interventions include fruit and vegetable produce prescription programs,10–12 food pantries,13–15 monthly food boxes,11 and farmers’ markets16–18 at health centers, clinics, and hospitals.
Previous research suggests that participation in healthcare-based food access interventions is facilitated by easy accessibility, trust in healthcare providers, and provision of nutrition education, which all likely reduce stigma associated with food assistance use.16,19–22 Although uptake is generally low, onsite food distributions typically yield higher participation rates than offsite referrals.23 Barriers include time and transportation constraints and fear of stigma.24 It has been hypothesized that patient uptake of food access interventions may vary by cultural and racial backgrounds.25 However, there is limited evidence15 on how patients’ sociodemographic characteristics are associated with uptake. Failing to fully comprehend and address factors influencing participation may perpetuate existing inequities. The authors used survey and interview data collected from health center patients enrolled in a monthly, free produce market to understand sociodemographic factors associated with program uptake, and barriers and facilitators to participation.
METHODS
Since March 2018, The Greater Boston Food Bank (GBFB) and Cambridge Health Alliance (CHA), a community healthcare system, have operated a monthly, free produce market at the CHA Revere Care Center in Revere, Massachusetts.26,27 Revere is a city north of Boston where 39% of residents are non-U.S.-born, more than 50% of households report a language other than English being spoken at home, and the median household income is 71% of the Massachusetts median household income.28 CHA Revere serves a low-income, diverse population where 47% have Medicaid insurance and the most common preferred languages of care are English (56%), Spanish (17%), Portuguese (15%), and Arabic (3%) (unpublished data). In 2017, pilot screening showed that 51% of patients at CHA Revere experienced food insecurity (unpublished data).
The market – held in the health center’s parking lot 1 Saturday morning each month – provides free, fresh produce to CHA patients and the public. GBFB delivers produce on the day of the market, and the health center promotes the market, distributes the food in a farmers-market style, and enrolls attendees in an attendance tracking database. Upon enrollment in the market, each patient is screened for previous attendance and provided a unique ID card that they present at each market to track attendance. Participants receive approximately 25 pounds of produce per visit. To maximize participation and reduce perceived stigma and administrative burden,29–31 the market is advertised as a healthy food market with no eligibility criteria (e.g., income, place of residence, medical diagnosis).
Study Sample
The Health Center PROgram to support fooD secUrity through nutrition Coaching and produce MarkEts (HC PRODUCE) study recruited participants from February 2019 through March 2020. Study participants were CHA primary care patients aged 18 years or older who had not previously attended the market. To recruit study participants, a CHA staff member fluent in English, Spanish, and Portuguese promoted the market in the primary care clinic waiting room, obtained informed consent, and enrolled patients in the study after they registered for the market. The market attendance tracking system was checked to ensure that a potential study participant had not already attended the market. During study enrollment, participants were assigned a unique ID to record future market attendance, which was used to link attendance and survey data. Due to COVID-19 and the need for social distancing, market attendance was only recorded through March 2020; follow-up time ranged from 1 to 14 months. Market promotion and reminders about upcoming markets were provided to all CHA Revere clinic patients in English, Spanish, Portuguese, and Arabic, and included emails, flyers/posters in clinic waiting rooms, CHA social media posts, and informal verbal encouragement by health center staff.
Measures
Baseline surveys were completed between February 2019 and April 2020 in English, Spanish, or Portuguese (the 3 most common languages spoken by CHA Revere patients) prior to first market visit. Participants were given the option to self-administer on a tablet or complete an interviewer-administered survey in-person or by phone. Race and ethnicity were self-reported. Preferred language of care was obtained from patients’ electronic medical records. General health status was measured the Healthy Days Measures.32 Household hunger was measured using a modified Household Hunger Scale.33 The scale was modified by combining 2-part questions into single questions to condense the scale from 6 to 3 questions. Hunger, often considered a severe form of food insecurity, was used rather than food insecurity because of a known high prevalence of food insecurity among CHA patients registering for the market. Participants were contacted by phone, text, or email to complete 1-year follow-up surveys, either online or by phone, between June 2020 and July 2021. The follow-up surveys included questions on barriers to market attendance.
To obtain in-depth information on barriers to and facilitators of market attendance, a concurrent qualitative study was conducted with a sample of HC PRODUCE study participants (n=45). A qualitative maximum variation sampling approach34 was used to include capture market experiences and attitudes associated with market use based on language (i.e., 15 English, 15 Spanish, and 15 Portuguese) and number of market visits (i.e., no visits, 1 visit, 6 or more visits). Participants were contacted by phone and invited to complete an open-ended interview. Upon verbal consent, participants completed the 30–45-minute phone interview between July and September 2020. The interview guide included questions organized under 3 domains: overall market experience, reasons for and challenges to market attendance (e.g., “According to registration records, I can see that even though you signed up for the free produce market, you haven’t gone to it. Can you tell me why?”), and recommendations for removing barriers to market attendance (e.g., “What would need to change for you to go to the market more often?”). Interviews were audio-recorded and professionally transcribed verbatim.
The CHA IRB approved all study procedures. Participants received Walgreens gift cards for completing the baseline survey ($10), follow-up survey ($20), and in-depth interview ($20).
Statistical Analysis
For the quantitative analysis, the sample was restricted to those likely to benefit from food assistance (i.e., those income-eligible for Supplemental Nutrition Assistance Program [SNAP]) based on household size and income, reporting using SNAP, food pantries, or The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the past 30 days, experiencing hunger according to the Household Hunger Scale, or reporting coping mechanisms to deal with hunger or purchasing unhealthy groceries due to economic constraints. The primary outcome, market attendance, was dichotomized as zero versus at least 1 market visit between March 2019 and March 2020, due to a relatively small number (n=96, 13.4%) attending the market more than once during follow-up. Robust Poisson regression models were used to estimate risk ratios for having attended the market at least once.35 Covariates in the adjusted model were age, sex, race/ethnicity, employment status, household income, marital status, household with children, preferred language of medical care, general health status, and use of food pantries or SNAP in the past 30 days. As follow-up time depended on when a participant enrolled in the study, the authors adjusted for follow-up time with a continuous variable ranging from 1 to 14 months. The missing indicator method was used for variables with values missing in at least 5% of participants.36 Participants with missing data on covariates that were missing in less than 5% of participants were excluded from baseline analyses. Missing indicators were used for income (missing in 6.3% of participants) and employment status (missing in 6.8% of participants). Statistical analyses were conducted using R software version 4.0.3.
For the qualitative study, a thematic analysis was conducted with all transcribed interviews using a combination of deductive and inductive coding approaches. Early stages of the coding process used a codebook developed from interview guide domains. As the coding process proceeded, the codebook was further refined with new codes inductively generated from the transcripts. Five trained members of the research team coded the interviews using Dedoose Qualitative Software.37 Additionally, early in the coding process, a random sample of the transcripts was used to ascertain appropriate interrater coding reliability. Coders completed a reflexivity memo created to document potential sources of interpretive bias during the coding and analysis processes.
RESULTS
During the study enrollment period, 1,075 CHA primary care patients registered for the market and 853 (79.3%) completed the baseline survey (Appendix Figure 1). Analyses were restricted to 715 (84.1%) participants (357 English, 232 Portuguese, and 126 Spanish) who enrolled through March 7, 2020 (the last market date before COVID-19 mitigation protocols required pausing market attendance tracking), were considered likely to benefit from food assistance, and had non-missing data on baseline covariates. Among these 715 participants, 514 (71.9%) completed the 1-year follow-up survey.
The plurality of participants were aged 30–49 years (n=345, 48.3%), female (n=585, 81.8%), Latino (n=441, 61.7%), married or living with a partner (n=407, 56.9%), living with children in their household (n=443, 62.0%), and with good, very good, or excellent self-rated health (n=407, 56.9%) (Table 1). One hundred and forty-three (20.0%) reported a household monthly income of <$1,000. The number of market visits during the 14-month study period ranged from 0 to 10, with 265 (37.1%) visiting the market at least once.
Table 1.
Baseline Characteristics of HC PRODUCE Quantitative Study (2019–2020) and Qualitative Sub-Study (2020) Participants by Produce Market Attendance
| Quantitative study | Qualitative study | ||||
|---|---|---|---|---|---|
| Produce market visitsa | |||||
| All (n=715) |
0 Visits (n=450) |
≥1 Visit (n=265) |
p-valueb | (n=45)c | |
| Characteristic | n (%) | n (%) | n (%) | n (%) | |
| Age group, years | 0.11 | ||||
| 18–29 | 118 (16.5) | 85 (18.9) | 33 (12.5) | 8 (17.8) | |
| 30–49 | 345 (48.3) | 211 (46.9) | 134 (50.6) | 17 (37.8) | |
| 50–69 | 220 (30.8) | 137 (30.4) | 83 (31.3) | 18 (40.0) | |
| ≥70 | 32 (4.5) | 17 (3.8) | 15 (5.7) | 2 (4.4) | |
| Sex | 0.08 | ||||
| Male | 130 (18.2) | 91 (20.2) | 39 (14.7) | 8 (18.2) | |
| Female | 585 (81.8) | 359 (79.8) | 226 (85.3) | 36 (81.8) | |
| Race/ethnicity | <0.001 | ||||
| Non-Hispanic White | 177 (24.8) | 119 (26.4) | 58 (21.9) | 7 (16.3) | |
| Non-Hispanic Black | 50 (7.0) | 34 (7.6) | 16 (6.0) | 2 (4.7) | |
| Hispanic or Latino | 441 (61.7) | 281 (62.4) | 160 (60.4) | 29 (67.4) | |
| Non-Hispanic Asian | 16 (2.2) | 3 (0.7) | 13 (4.9) | 2 (4.7) | |
| Non-Hispanic Middle Eastern/North African | 13 (1.8) | 5 (1.1) | 8 (3.0) | 1 (2.3) | |
| Otherd | 18 (2.5) | 8 (1.8) | 10 (3.8) | 5 (11.6) | |
| Preferred language for medical care | 0.009 | ||||
| English | 311 (43.5) | 213 (47.3) | 98 (37.0) | 15 (33.3) | |
| Language other than English | 404 (56.5) | 237 (52.7) | 167 (63.0) | 30 (66.6) | |
| Marital status | 0.01 | ||||
| Single | 165 (23.1) | 120 (26.7) | 45 (17.0) | 11 (26.2) | |
| Separated, divorced, widowed | 143 (20.0) | 86 (19.1) | 57 (21.5) | 5 (11.9) | |
| Married or living with partner | 407 (56.9) | 244 (54.2) | 163 (61.5) | 26 (61.9) | |
| Children in household | 0.14 | ||||
| Yes | 443 (62.0) | 269 (59.8) | 174 (65.7) | 28 (62.2) | |
| No | 227 (37.9) | 182 (40.2) | 90(35.1) | 17 (37.8) | |
| Employmente | 0.11 | ||||
| Employed | 417 (62.6) | 278 (65.3) | 139 (5.9) | 25 (59.5) | |
| Disabled | 91 (13.7) | 60 (14.1) | 31 (12.9) | 4 (9.5) | |
| Homemaker | 90 (13.5) | 50 (11.7) | 40 (16.7) | 10 (23.8) | |
| Retired | 31 (4.7) | 14 (3.3) | 17 (7.1) | 2 (4.8) | |
| Student | 8 (1.2) | 5 (1.2) | 3 (1.2) | 1 (2.4) | |
| Unemployed | 29 (4.4) | 19 (4.5) | 10 (4.2) | ||
| Household incomef | 0.02 | ||||
| <$1,000 | 143 (21.4) | 78 (18.6) | 65 (26.2) | 9 (25.0) | |
| $1,000–$2,499 | 255 (38.2) | 158 (37.6) | 97 (39.1) | 18 (50.0) | |
| ≥$2,500 | 270 (40.4) | 184 (43.8) | 86 (34.7) | 9 (25.0) | |
| Household Hunger Scale category | 0.87 | ||||
| No/little hunger | 622 (87.0) | 391 (86.9) | 231 (87.2) | 38 (86.4) | |
| Moderate hunger | 46 (6.4) | 28 (6.2) | 18 (6.8) | 3 (6.8) | |
| Severe hunger | 47 (6.6) | 31 (6.9) | 16 (6.0) | 3 (6.8) | |
| Live in city of Revere | 0.002 | ||||
| Yes | 283 (39.6) | 158 (35.1) | 125 (47.2) | 14 (68.9) | |
| No | 432 (60.4) | 292 (64.9) | 140 (52.8) | 31 (31.1) | |
| Self-reported health | 0.80 | ||||
| Good, very good, or excellent | 407 (56.9) | 254 (56.4) | 153 (57.7) | 26 (59.1) | |
| Poor or fair | 308 (43.1) | 196 (43.6) | 112 (42.3) | 18 (40.9) | |
| SNAP use | 0.62 | ||||
| Yes | 172 (24.1) | 105(23.3) | 67 (25.3) | 8 (18.2) | |
| No | 543 (75.9) | 345 (76.7) | 198 (74.7) | 36 (81.8) | |
| Food pantry use | 0.91 | ||||
| Yes | 70 (9.8) | 45 (10.0) | 25 (9.4) | 0 (0.0) | |
| No | 645 (90.2) | 405 (90.0) | 240 (90.6) | 44 (100.0) | |
| Market visits | <0.001 | ||||
| 0 | 450 (62.9) | – | – | 15 (33.3) | |
| 1 | 168 (23.5) | – | – | 16 (35.6) | |
| 2–5 | 76 (10.6) | – | – | 0 (0.0) | |
| ≥6 | 21 (2.9) | – | – | 14 (31.1) | |
| Follow-up time, months, median [IQR] | 7 [4, 9] | 7 [4, 9] | 7 [4, 10] | 0.36 | 11 [9, 11] |
Notes: Boldface indicates statistical significance (p<0.05).
Market attendance was recorded between March 2019 and March 2020. Market attendance from April 2020 onward was temporarily suspended due to the COVID-19 pandemic.
P-values calculated by chi-square tests.
Not all numbers sum to 45 because some qualitative study participants were missing quantitative data.
n=666, missing 49.
n=668, missing 47.
HC PRODUCE, Health Center PROgram to support fooD secUrity through nutrition Coaching and produce MarkEts; SNAP, Supplemental Nutrition Assistance Program.
In multivariable models, patient factors associated with attending the market at least once were being 30-49 years old (RR=1.36, 95% CI=1.00, 1.86); identifying as Asian (RR=2.48, 95% CI=1.58, 3.89) or “other” race (RR=1.63, 95% CI=1.05, 2.55) compared to White race; having a preferred language of medical care other than English (RR=1.35, 95% CI=1.03, 1.76); having a monthly household income of <$1,000 (RR=1.73, 95% CI=1.29, 2.32) or $1,000–$2,499 (RR=1.28, 95% CI=1.01, 1.63) compared to ≥$2,500; being retired compared to being employed (RR=1.90, 95% CI=1.17, 3.08); and living in Revere, the market’s location, (RR=1.36, 95% CI=1.12, 1.63) (Table 2).
Table 2.
Association Between HC PRODUCE Study Participants’ Characteristics and Produce Market Attendance, n=715
| Unadjusteda | Adjusted | |||
|---|---|---|---|---|
| Characteristic | Risk ratio (95% CI) | p-value | Risk ratio (95% CI) | p-value |
| Age group, years | ||||
| 18–29 | ref | ref | ||
| 30–49 | 1.39 (1.01, 1.92) | 0.04 | 1.36 (1.00, 1.86) | 0.05 |
| 50–69 | 1.34 (0.96, 1.88) | 0.09 | 1.38 (0.97, 1.97) | 0.08 |
| ≥70 | 1.68 (1.06, 2.68) | 0.03 | 1.24 (0.69, 2.26) | 0.47 |
| Sex | ||||
| Male | ref | ref | ||
| Female | 1.28 (0.97, 1.70) | 0.08 | 1.24 (0.93, 1.65) | 0.14 |
| Race/ethnicity | ||||
| Non-Hispanic White | ref | ref | ||
| Non-Hispanic Black | 0.98 (0.62, 1.66) | 0.94 | 1.05 (0.66, 1.65) | 0.85 |
| Hispanic or Latino | 1.12 (0.87, 1.42) | 0.38 | 1.01 (0.71, 1.44) | 0.96 |
| Non-Hispanic Asian | 2.42 (1.76, 3,34) | <0.001 | 2.48 (1.58, 3.89) | <0.001 |
| Non-Hispanic Middle Eastern / North African | 1.89 (1.18, 3.03) | 0.008 | 1.49 (0.86, 2.58) | 0.15 |
| Other | 1.71 (1.08, 2.71) | 0.02 | 1.63 (1.05, 2.55) | 0.031 |
| Preferred language for medical care | ||||
| English | ref | ref | ||
| Language other than English | 1.33 (1.09, 1.62) | 0.006 | 1.35 (1.03, 1.76) | 0.03 |
| Marital status | ||||
| Single | ref | ref | ||
| Separated, divorced, widowed | 1.45 (1.05, 2.00) | 0.02 | 1.36 (0.98, 1.88) | 0.06 |
| Married or living with partner | 1.47 (1.11, 1.94) | 0.006 | 1.31 (0.98, 1.75) | 0.07 |
| Children in household | ||||
| Yes | 1.19 (0.97, 1.46) | 0.09 | 1.16 (0.92, 1.46) | 0.22 |
| No | ref | ref | ||
| Employment | ||||
| Employed | ref | ref | ||
| Disabled | 1.01 (0.73, 1.38) | 0.97 | 1.09 (0.75, 1.59) | 0.65 |
| Homemaker | 1.31 (1.01, 1.72) | 0.05 | 1.13 (0.86, 1.47) | 0.39 |
| Retired | 1.62 (1.14, 2.31) | 0.007 | 1.90 (1.17, 3.08) | 0.01 |
| Student | 1.14 (0.46, 2.84) | 0.78 | 1.86 (0.67, 5.16) | 0.23 |
| Unemployed | 1.01 (0.60, 1.69) | 0.98 | 1.11 (0.62, 1.97) | 0.73 |
| Household income | ||||
| <$1,000 | 1.40 (1.08, 1.82) | 0.01 | 1.73 (1.29, 2.32) | <0.001 |
| $1,000–$2,499 | 1.18 (0.93, 1.50) | 0.18 | 1.28 (1.01, 1.63) | 0.05 |
| ≥$2,500 | ref | ref | ||
| Household Hunger Scale category | ||||
| No/little hunger | ref | ref | ||
| Moderate hunger | 1.03 (0.71, 1.51) | 0.86 | 0.99 (0.68, 1.45) | 0.98 |
| Severe hunger | 0.89 (0.59, 1.34) | 0.57 | 1.04 (0.67, 1.61) | 0.985 |
| Live in city of Revere | ||||
| Yes | 1.36 (1.13, 1.64) | 0.001 | 1.36 (1.12, 1.63) | 0.001 |
| No | ref | ref | ||
| General health status | ||||
| Good, very good, or excellent | ref | ref | ||
| Poor or fair | 0.96 (0.79, 1.17) | 0.70 | 0.97 (0.79, 1.19) | 0.76 |
| SNAP use | ||||
| Yes | 1.05 (0.85, 1.31) | 0.64 | 0.76 (0.79, 1.27) | 0.90 |
| No | ref | ref | ||
| Food pantry use | ||||
| Yes | 1.04 (0.75, 1.44) | 0.83 | 0.92 (0.66, 1.28) | 0.62 |
| No | ref | ref | ||
| Follow-up time, months | 1.01 (0.99, 1.04) | 0.30 | 0.99 (0.97, 1.02) | 0.69 |
Notes: Boldface indicates statistical significance (p<0.05).
Adjusted only for follow-up time.
HC PRODUCE, Health Center PROgram to support fooD secUrity through nutrition Coaching and produce MarkEts; SNAP, Supplemental Nutrition Assistance Program.
According to the 1-year follow-up survey, the most common reasons for not attending the market were lack of time (n=142, 28%), forgetfulness (n=117, 23%), work conflict (n=116, 23%), lack of information about the market location or date (n=115, 22%), lack of transportation (n=62, 12%), not wanting to wait in line (n=60, 12%), and dealing with a medical condition (n=50, 10%) (Table 3). Those who had not attended the market were more likely to report barriers to attendance compared to those who had attended 6 or more times; this was particularly true for barriers related to convenience and time commitments. However, even those who attended the market multiple times faced challenges in attending the market; among those who attended the market at least 6 times, the most common barriers to attending were not wanting to wait in line (24%), forgetfulness (24%), childcare (18%), lack of time (18%), unsure of market location/date/time (18%), and poor weather (12%).
Table 3.
Reported Reasons for Not Attending the Produce Market Ever or Always, From 1-Year Follow-Up Survey Data, (2020–2021), n=514
| Produce market visits |
|||||
|---|---|---|---|---|---|
| Reason for not attending the produce market | All (n=514) n (%) |
0 Visits (n=302) n (%) |
1 Visit (n=131) n (%) |
2–5 Visits (n=64) n (%) |
≥6 Visits (n=17) n (%) |
| I didn’t have time | 142 (28) | 89 (29) | 39 (30) | 11 (17) | 3 (18) |
| I had to work | 116 (23) | 71 (24) | 32 (24) | 11 (17) | 2 (12) |
| I forgot about it | 117 (23) | 78 (26) | 22 (17) | 13 (20) | 4 (24) |
| I wasn’t sure of the date, time, or location of the market | 115 (22) | 69 (23) | 27 (21) | 16 (25) | 3 (18) |
| I didn’t want to wait in line | 60 (12) | 32 (11) | 15 (11) | 9 (14) | 4 (24) |
| I didn’t have a way to get to the market | 62 (12) | 38 (13) | 17 (13) | 7 (11) | 0 (0) |
| I had to take care of my child | 54 (11) | 33 (11) | 16 (12) | 2 (3) | 3 (18) |
| I felt that others needed the food more than I did | 39 (8) | 28 (9) | 8 (6) | 2 (3) | 1 (6) |
| The market is too far from where I live | 47 (9) | 33 (11) | 10 (8) | 4 (6) | 0 (0) |
| I was dealing with a medical condition | 50 (10) | 26 (9) | 13 (10) | 11 (17) | 0 (0) |
| I didn’t need the food offered | 27 (5) | 17 (6) | 6 (5) | 3 (5) | 1 (6) |
| I have moved out of the area | 25 (5) | 14 (5) | 7 (5) | 4 (6) | 0 (0) |
| I didn’t attend because the weather was bad | 23 (5) | 11 (4) | 5 (4) | 5 (8) | 2 (12) |
| I wasn’t sure of eligibility requirements | 19 (4) | 15 (5) | 2 (2) | 1 (2) | 0 (0) |
| I didn’t want the food offered | 11 (2) | 5 (2) | 4 (3) | 2 (3) | 0 (0) |
| I felt like people would judge me for attending the market | 5 (1) | 3 (1) | 2 (2) | 0 (0) | 0 (0) |
| I didn’t want only fruits and vegetables | 4 (1) | 2 (1) | 1 (1) | 1 (2) | 0 (0) |
| People at the market don’t speak my language | 3 (1) | 1 (1) | 1 (1) | 0 (0) | 0 (0) |
Notes: Other reasons for not attending the produce market: family obligation (n=4), out of town (n=4), bags too heavy to transport (n=3), unaware of market (n=3), death in family (n=2), quantity of food was too small (n=1), quality of produce (n=1), no reminder sent (n=1), doesn’t want to receive assistance (n=1), lost produce market ID card (n=1), other obligations (n=1).
The qualitative data (Table 4) confirmed and amplified quantitative findings. Participants described the many transportation challenges they faced including traveling long distances using public transportation, not having a car, or relying on others to attend the market. These challenges were compounded by having difficulty carrying heavy bags of market produce home. Competing demands and scheduling conflicts, particularly for those with children, also emerged as barriers to market attendance. Many participants’ work and family responsibilities, combined with the market’s limited hours, prevented them from attending. Stigma did not emerge as a barrier, but participants did report that they did not use the program for fear of taking food away from others in greater need. Regarding facilitators to market attendance, participants spoke at length about a desire for fresh produce, particularly for their children, which was viewed by many as healthful yet prohibitively expensive. Exposure to new types of produce offered at the market was an additional reported incentive for returning to the market. Some participants highlighted that hearing about the market from their healthcare provider and the fact that it was sponsored by their health clinic made the market feel more welcoming.
Table 4.
Participant-Reported Barriers and Facilitators to Market Use
| Theme | Supporting quotes |
|---|---|
| Barriers | |
| Accessibility | |
| Limited market hours | “The day is fine, the hours are very few. It’s [only] one hour, not enough.” - Spanish interview, 0 market visits “…I went and it seems that it was too late, because it seems that it’s very few hours…” - Spanish interview, 0 market visits |
| Forgetfulness | “…I had a newborn baby and she was sleeping and every time I remembered ‘my God it was a week ago!’” - English interview, 0 market visits “I just mess up the schedule I think.” - English interview, 0 market visits “The truth is that I haven’t gone once because…I’m already 64 years old and I forget.” – Spanish interview, 1 market visit “…I don’t remember, well, the paper [flyer], the [market’s] dates have passed, I just haven’t gone back…” - Spanish interview, 1 market visit |
| Transportation issues | “I wanted to [go], but I had no car. The one time I went was with a friend who was also there to collect food, so I hitched a ride. My baby was born shortly after and it became difficult to ask for a ride with one more. Then I moved after a while. I now live very far away.” - Portuguese interview, 1 market visit “I have gone about twice …because I have not had a car for [inaudible], both times with the car that has made it difficult for me to take the bus.” - Spanish interview, 1 market visit “The main difficulty was that we had just arrived from Brazil. We hadn’t been here long and we didn’t have a car. We only bought a car some three months ago, so now we have a car. So then it was difficult for us to go there, as I live in Everett.” - Portuguese interview, 1 market visit “It’s because I end up without a car, so I can’t go to Revere.” - Portuguese interview, 0 market visits “… there is no car, we have no car. …transport is quite difficult also.” - Spanish interview, 0 market visits |
| COVID-19 | “Due to the pandemic [did not go to the market], we have been a little afraid of going [for fear] to expose myself and my children, I have not returned.” - Spanish interview, 1 market visit “For the same thing that I say, due to the coronavirus. The coronavirus. …It has scared me, it is not like when that [COVID] was not there, well I was relaxed on the bus and that, now it seems that one does not want the children to get sick and neither does one.” - Spanish interview, 6+ market visits |
| Competing demands and schedule conflicts | “I was busy with the kids or I have something to do something else to do” - English interview, 6+ market visits “Because I always know-- that it was on Saturdays and it was no more than two and a half hours and in those hours where they had it I had-- sometimes I have other things to do, I don’t have a car, it’s a bit away from my house and many other things to do, that’s why I no longer went, and after that, I was also in a class of - I don’t remember what the class I had was, I don’t know if it was Bible school… so I could not go and had no one to send [to pick up the produce].” - Spanish interview, 0 market visits “On Saturday, yeah, the fact is that I work in a beauty salon. This means that Saturday is my busiest day as well.” - Portuguese interview, 0 market visits “So I do choose when I go because sometimes I either have to go to work very early or work in the morning, then I have to organize the schedule and know that there I am going to spend two hours to be able to get out of there.” - Spanish interview, 1 market visit “The only thing is then that I work at night, that’s why I have not been. As I work… at night and I go out at seven in the morning, yes, what I get is sometimes to lie down to sleep and rest.” - Spanish interview, 1 market visit |
| Physical challenges | “By bus…. And then… to go with a cart like that to put things in and push it. Yes, it has been very difficult for me because I suffer from my back and legs.” - Spanish interview, 1 market visit “The line was quite long the last time I went. It had been difficult for me, that’s why I have back and foot problems. They hurt me if I’m standing a lot.” Spanish interview, 1 market visit |
| Market experience | |
| Bad weather | “Sometimes it was the weather was like really hot…” - English interview, 6+ market visits “And then in the winter months, of course, I don’t go, in real bad weather and stuff.” - English interview, 6+ market visits |
| Long lines | “The day I went there was a line and then I didn’t go anymore.” - Spanish interview, 0 market visits “I would say maybe three or four times the line is so long. So I have a bad back, so I can’t really stand too long, so I only went about three or four times.” - English interview, 1 market visit “Well I would love to [go to the market again]. Like I said I’ve driven by a lot of times. And as soon as I saw the line [during COVID] I just like oh you know I don’t even know if they’re going to have enough bags or should I risk it or so I would just leave I would just go and go home.” - English interview, 6+ market visits |
| Lack of need for food assistance | |
| Concern that others have greater need | “And after the pandemic we just said no there’s people that need some more than that.” – English interview, 0 market visits “Financially I thought that, you know, there were more people that needed free food more than me.” – English interview, 0 market visits “I needed it at the time, then later I thought, ‘I think others need more than I do,’ so I didn’t return.” – Portuguese interview, 1 market visit “I said I had been in a position earlier before my ex died where I needed to go to food banks and if I was still in that position I would have been going back and taking advantage of it. But I feel that it’s you know it’s not right if you can if you can afford groceries to do to you to take them away… I have very strong feelings about not taking from some cause as I said when I needed it I needed it certain the food banks and that kind of help. And yeah it was wonderful when I needed it.” – English interview, 6+ market visits |
| Facilitators | |
| Acceptability | |
| Health care clinic sponsorship/setting | “…it [the market] showed me that my health insurance plan or my health clinic cares about its customers and wants to improve their health by offering vegetables fruits that maybe some people have never tried before.” – English interview, 6+ market visits “…coming [produce market] from your provider or something, it would just seem a bit more relaxed and ok about it. And that is part of it and a part of the health care thing rather than being stigmatized as being a financial [situation].” – English interview, 6+ market visits |
| Market experience and offerings | |
| Exposure to new fruits and vegetables | “I felt it was a good resource that I wasn’t aware of, and in the winter months going there, I was able to try different vegetables that growing up my mom never made. So, I got to try different foods that I had never tried before. So that was a good thing too. So, there were, probably, two or three different varieties that I had never tried before and they were really good. So I was surprised. So I tried different things, different items that I had never had before.” - English interview, 6+ market visits “…I have two children and it helped help me out with fruits and vegetables so I could give to my kids as well. Then trying something new like pumpkin. They gave pumpkins out so they gave different foods that I never tried before. - English interview, 6+ visits “… It was a vegetable that I had never eaten before, and didn’t even know it was edible. They gave it to me and then I researched it and, yes indeed, it was a vegetable. …I liked it, yes indeed. I remember that at the time I even used it to make soup. The soup was very tasty.” - Portuguese interview, 6+visits “I had never eaten eggplant and there was a time when some eggplant came and went, so my mom made them stuffed.” - Spanish interview, 6+ visits |
| Perceived value | |
| Need for food assistance | “I feel like it’s definitely a blessing and it’s helped me. And in my time of need, so to speak, it has been a big help, and I truly appreciate it. And it’s given me, you know, different options that I might not choose. So it’s been good learning how to cook different things. So it has been a big help.” – English interview, 6+ market visits “For me it is something very important, do you understand? Because they are things that you can use, they really help you a lot to fill the fridge, they are fresh vegetables and all that, for me that is very important. …You need them a lot, I need them a lot, well, I, mainly I need them a lot, imagine. Because I don’t work, imagine, I am disabled, they are things that I like, imagine.” - Spanish interview, 1 market visit “I think every little bit helps, honestly, with this-- I mean, now thankfully I’m getting back to normal for quite some hours, but in the beginning of like the first few months of the virus our hours were definitely cut because we weren’t seeing as many patients. So it was a big help. I look forward to it and it does help me. I really feel like it’s a godsend. It’s been a big help.” - English interview, 6+ visits “Because we need it, so you make the effort to… go get it because it’s something very important: fruits for my children. Because sometimes one does not have enough to buy fruit. …I am a single mother, I earn [very] little and then it [the market] is a help. I feel that it helps me a lot” - Spanish interview, 6+ visits |
| Access to healthy food | “So I don’t always get to the bigger stores to be able to get-- I tend to have more canned vegetables than fresh ones just because it’s difficult sometimes to get to the stores. And I think it just-- I felt like it gave me additional better options, I guess. Healthier options, so.” - English interview, 6+ market visits “Well, it’s because we always have fresh fruit and vegetables, and this encouraged us even more because I always try to eat well, and improve even more by having healthy eating habits.” - Portuguese interview, 6+ market visits “It’s sort of like you know it’s free. You could try it and if they like it they could continue with it you know which improves their health.” - English interview, 6+ market visits “…they are fresh fruits and vegetables and they are healthy.” - Spanish interview, 6+ market visits |
DISCUSSION
This mixed-methods study sought to understand patient sociodemographic factors and personal experiences associated with barriers and facilitators to use of a monthly produce market offered at a health center. Quantitative methods were used to assess the role of sociodemographic characteristics on market use, and qualitative findings provided experiential information from market attendees and non-attendees on life circumstances and dynamics that impacted their market attendance.
Patients less likely to attend the market were younger, white, had higher incomes, were employed, lived farther away, and had English as their preferred language of medical care. Quantitative and qualitative findings showed that barriers to participation include lack of time, work conflicts, childcare needs, competing demands, lack of transportation, lack of information about the market location or time, forgetfulness, and dealing with medical conditions. Among those who attended the market frequently, not wanting to wait in line, forgetfulness, and competing demands were barriers to attendance.
Most patients faced challenges to attending; even those who attended multiple times had to overcome barriers to visit the market. The market was visited when convenient to access in terms of time availability, transportation, and proximity to home address. In households with children, interviews found that although feeding their children healthy food was a major motivator for attendance, many patients faced barriers to attendance related to childcare and other competing time needs. This highlights the complex situations of patients that may benefit from, and desire to attend, a free produce market, yet be limited by competing demands.
The market’s lack of eligibility requirements may have allowed some to attend who may have been ineligible for other forms of food assistance. For example, patients whose preferred language of medical care was not English were more likely to attend the market. A language of care other than English may be seen as a proxy for immigration status, which often presents additional barriers to accessing federal food and financial assistance (e.g., SNAP, unemployment benefits) for immigrants due to systemic barriers such as eligibility status, fear of impact on immigration status, language barriers, and lack of knowledge of available programs.14,38,39,27 Healthcare-based food access interventions, which often require less documentation than federal food assistance or typical food pantries, may be preferred by immigrants unable to easily access other forms of food assistance.
Although Asian and “other” race groups made up a small proportion of the study sample, they were more likely to attend the market. While this study does not examine reasons for this finding, other studies have shown that in some Asian communities, level of acculturation, being non-U.S. born, and country of origin were predictors of food insecurity,40 and that the public charge rule remained a concern for those applying for visa extensions or permanent resident status.39,41 It is possible that there are complex reasons for increased attendance at the market among these subgroups that are beyond the scope of this study. Further research may examine the relationship between disaggregated racial/ethnic groups, language, immigration status, and food assistance use within the U.S. sociocultural context.
Although the market welcomed all patients regardless of need, and did not require a positive food insecurity screen, those with the lowest incomes, which may reflect a high need for food assistance, were the most likely to attend. In fact, some individuals opted not to visit the market so that others with more financial need could benefit from it. Removing eligibility requirements may have facilitated uptake by patients in greater need, which is consistent with other work on accessibility of, and stigma around, food assistance programs.29,42 Moreover, these findings may be supported by the theory of allostatic load,43 whereby complying with additional eligibility and enrollment requirements may become increasingly burdensome in a context where multiple stressors are already present, such as with poverty.43 This may be a reason why the current findings did not show a relationship between SNAP or food pantry use and market attendance, perhaps indicating that some who were not using other food assistance programs were attending the market instead.
Qualitative findings aligned with previous research showing that hospital-based food access interventions are one option to provide food assistance in low-stigma environments.31 Qualitative findings identified that major drivers of attendance were having the opportunity to obtain free, healthy food in an environment with reduced stigma due to the market being located at a health center where some patients expressed feeling comfortable and welcomed by staff volunteering at the market. These findings suggest that produce markets located at and run by healthcare centers may facilitate patients’ use of food distribution programs.30 Providing health center based food assistance to all patients, without requiring specific medical diagnoses or a positive screen for food insecurity, may be of interest to other healthcare-based programs that seek to serve patients in need but have limited administrative resources to screen for food insecurity or select patients based on medical diagnoses. However, it is possible that targeted referrals based on medical diagnoses or food insecurity screens could have also promoted market attendance. Further research should study the effect of targeted referrals on produce market attendance compared to programs open to all patients.
As barriers prevented some patients from accessing the market, program modifications are necessary to improve accessibility while maintaining high levels of acceptability. Research findings have spurred quality improvement projects for the market including text message reminders and assistance with transportation via taxi vouchers and home delivery of groceries to medically indicated patients. Targeted outreach and marketing strategies to increase market attendance could be informed by focusing on facilitators of high acceptability that were identified through qualitative interviews. For example, marketing materials could highlight the variety of produce items and the fact that the market is supported by and located at the health center. Future research could examine the effectiveness of text message reminders, transportation assistance, and marketing materials.
Limitations
The authors stopped tracking market attendance at the start of the pandemic to comply with COVID-19 mitigation protocols, which decreased the follow-up period during which study participant market attendance was recorded. As data other than market attendance was self-reported, there is the possibility of social desirability bias, which could have led patients to understate barriers to market use. Although the present findings may be generalizable to urban healthcare centers serving primarily low-income patients, barriers to market use in other settings, such as in rural areas, may differ due to the need to travel greater distances or other unique considerations. Due to the small sample of many racial/ethnic groups, the authors could not examine differences in program participation by some groups individually.
CONCLUSIONS
Study findings suggest that healthcare-based food access interventions have the potential to reach individuals with unmet food needs who cannot, or would not, access other forms of food assistance. However, despite patients’ expressed desire for fresh produce and motivation to attend the market, actual use of the market was often limited by the presence of barriers such as time limitations (e.g., work schedule, childcare, and competing demands), physical limitations (e.g., medical conditions, long lines, and heavy bags of market produce) and transportation limitations. This study helps depict the complex situations patients experience that may prevent them from benefitting from health center-based food assistance programs. These findings could help inform policies at food assistance programs working to reduce burdens on participants and may also help inform city/town policies to improve participation in local food distribution programs.
Supplementary Material
ACKNOWLEDGMENTS
We are grateful to Cambridge Health Alliance Revere Care Center patients and staff, survey interviewers, and the in-depth interviewers and coders (Margo Moyer, Juliana Libardi Maia, and Anika Kumar). This study was supported by the Massachusetts Attorney General Office’s Social Determinants Partnership grant and a grant from the Social Interventions Research and Evaluation Network, with funding from the Robert Wood Johnson Foundation. Dr. Fiechtner is supported by grant number K23HD090222 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. No financial disclosures were reported by the authors of this paper.
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