State-Level Farmers Market Activities: A Review of CDC-Funded State Public Health Actions That Support Farmers Markets

Abstract

Context

Introducing farmers markets to underserved areas, or supporting existing farmers markets, can increase access and availability of fruits and vegetables and encourage healthy eating. Since 2003, the Centers for Disease Control and Prevention (CDC)’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) has provided guidance and funding to state health departments (SHDs) to support the implementation of interventions, including activities around farmers markets, to address healthy eating, and improve the access to and availability of fruits and vegetables at state and community levels.

Objective

For this project, we identified state-level farmers market activities completed with CDC’s DNPAO funding from 2003 to 2013. State-level was defined as actions taken by the state health department that influence or support farmers market work across the state.

Design and Participants

We completed an analysis of SHD farmers market activities of 3 DNPAO cooperative agreements from 2003 to 2013: State Nutrition and Physical Activity Programs to Prevent Obesity and Other Chronic Diseases; Nutrition, Physical Activity and Obesity Program; and Communities Putting Prevention to Work. To identify state farmers market activities, data sources for each cooperative agreement were searched using the key words “farm,” “market,” “produce market,” and “produce stand.” State data with at least one state-level farmers market action present were then coded for the presence of itemized activities.

Results

Across all cooperative agreements, the most common activities identified through analysis included the following: working on existing markets and nutrition assistance benefit programs, supporting community action, and providing training and technical assistance. Common partners were nutrition assistance benefit program offices and state or regional Department of Agriculture or agricultural extension offices.

Implications for Policy & Practice

Common farmers market practices and evidence-based activities, such as nutrition assistance benefits programs and land-use policies, can be adopted as methods for farmers market policy and practice work.

Conclusion

The activities identified in this study can inform future planning at the state and federal levels on environment, policy, and systems approaches that improve the food environment through farmers markets.

The number of farmers markets in the United States has increased significantly in the last 10 years, from 3706 in 2004 to 8268 in 2014.¹ This increase may be attributed to growing consumer interest,² support by nongovernmental organizations (eg, Wholesome Wave), and local, state, and federal efforts. Farmers markets support local farming economies through direct-to-consumer venues for farmers to sell their products and provide gathering spots for consumers and members of the community.² They also provide an access point for people to purchase fresh fruits, vegetables, and other food items³ and may serve as a method to increase the availability of healthier foods.⁴ Providing greater availability and access to healthier foods such as fruits and vegetables is a public health strategy for increasing their consumption.^5–7 Eating fruits and vegetables lowers the risk of developing many chronic diseases and provides essential nutrients that are vital for good health.⁸

The ability to access fresh fruits and vegetables at farmers markets can be particularly important in underserved areas or areas with few retail venues to purchase healthy foods.^9,10 Public health efforts to increase the ability of low-income consumers to access farmers markets in underserved areas may include facilitating the acceptance of nutrition assistance benefit programs. Farmers markets can accept Electronic Benefits Transfer (EBT) cards for the Supplemental Nutrition Assistance Program (SNAP) or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) coupons or vouchers. Some programs incentivize SNAP recipients to shop at farmers markets by providing a financial match for SNAP purchases, such as giving a dollar match for every $5 spent to purchase fruits and vegetables.^11,12 However, there are many farmers markets that do not facilitate the acceptance of nutrition assistance benefit programs, which may limit lower income consumers’ ability to shop at this venue.

CDC Support for Farmers Markets

Although traditionally farmers market programs have been supported by the United States Department of Agriculture and other agriculture programs and partners, they have also been used as a strategy by several programs funded by the Centers for Disease Control and Prevention (CDC).

Since 2003, CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) has provided guidance and funding to state health departments (SHDs) to support the implementation of interventions, including activities around farmers markets, to address healthy eating and improve the access to and availability of fruits and vegetables at state and community levels.

DNPAO assists the work of its state and community grantees by providing implementation and evaluation guidance, technical assistance and training, surveillance data and reports, applied research findings, and national partnership support. The guidance from DNPAO to its SHD grantees has changed over time. Around 2008, there was a shift in focus from individual-level strategies to policy, systems, and environmental change (PSE) strategies to increase the reach and impact of grantees’ activities. PSE change strategies can create sustainable changes in communities and encourage healthy behaviors to ultimately reduce the burden of chronic disease.¹³ Farmers market activities can include elements of both individual-level and PSE strategies. For example, providing nutrition education at existing farmers markets is an individual-level strategy. Creating a new market or increasing the amount of fruits and vegetables at an existing market is a PSE strategy because it focuses on improving the food environment.

DNPAO has not only given guidance to grantees to encourage PSE farmers market strategies, but has also given grantees the flexibility to pursue activities that focus on a few communities in their state, activities that reach communities across their state, or a combination of these. Activities that support farmers markets across a state can enhance the reach of farmers markets, potentially increasing accessibility and affordability of fruits and vegetables to a wide proportion of a state’s population. For this project, we wanted to identify state-level farmers market activities completed with CDC’s DNPAO funding from 2003 to 2013.

State-Level Farmers Market Activities

Local health department involvement in farmers market projects has been documented, such as incentive programs,⁵ nutrition assistance benefit programs,¹⁴ and nutrition education.¹⁵ Some literature describes the SHD’s role in individual farmers market projects.^16–18 However, there is a lack of literature that describes the activities of SHDs to support farmers market work across their states. To help address this gap, we assessed SHD farmers market activities by DNPAO grantees from 2003 to 2013. This article provides examples of the roles SHDs have played in supporting farmers market work at the state-level and could help generate ideas for future state-level farmers market efforts.

Methods

We completed an analysis of SHD farmers market activities of 3 DNPAO cooperative agreements from 2003 to 2013: State Nutrition and Physical Activity Programs to Prevent Obesity and Other Chronic Diseases (03022); Nutrition, Physical Activity and Obesity Program (805); and Communities Putting Prevention to Work (CPPW) (see Table 1, Supplemental Digital Content 1, available at: http://links.lww.com/JPHMP/A214, for cooperative agreement and data source descriptions). No institutional review board approval was required for this study because data were obtained from an existing, de-identified dataset and did not entail human subjects research.

Because reporting forms and requirements changed with each cooperative agreement, the data collection methodology changed over time. Data were reported by grantee staff and reviewed by CDC project officers and contractors. For 03022, states submitted annual performance reports and a state final report at the end of the program. For 805, states submitted annual activities to the State Program Interim Reporting System (SPIRS) Microsoft Excel database and a state final report at the end of the program. For CPPW, states submitted a final evaluation report at the end of the program. Cooperative agreement reporting requirements were flexible and qualitative, prompting open-ended responses for activities, such as a description of environmental changes implemented or partnerships developed. States were not specifically asked to report on farmers market activities.

Inclusion criteria for state activities

For the purpose of this project, farmers markets included a market where a recurring gathering of farmers sells their food products directly to consumers, a permanent or seasonal produce market or stand, or a single farmer selling directly to consumers at a fixed location, such as a farm stand.¹⁹ These markets can

• be held on public or private land, in temporary or permanent structures, or may be mobile;

• be set up in community locations, health clinics, places of worship, schools, hospitals, or workplaces; and

• include locally or regionally grown items and farm fresh produce.

For the purpose of this analysis, the definition of farmers markets did not include Community-Supported Agriculture programs.

To identify state farmers market activities, the data sources were searched using the key words “farm,” “market,” “produce market,” and “produce stand.” The first search looked through state final reports and performance reports of all 28 recipients of 03022 funds and state final reports of all 25 recipients of 805 funds. Next, all 4 SPIRS reports were searched for each state (2008–2009, 2009–2010, 2010–2011, and 2011–2012). Then final evaluation reports for CPPW were searched. Relevant data were identified using the keywords and selected on the basis of the aforementioned criteria of a farmers market; these data were copied into a Microsoft Excel spreadsheet. Activities that did not pertain to farmers markets were excluded. For example, data identified by the word “farm”were excluded if they referred to a “farm-to-school” program. Data identified by the word “market” were excluded if they referred to a “marketing” program that did not involve work or activities with a farmers market.

Coding and analysis

The qualitative analysis was primarily deductive. Coding categories and definitions were developed before reviewing the reports on the basis of previous knowledge of the work of SHDs. In addition, some inductive methods were used, when we refined and added coding categories and definitions as needed during the coding process and analyzed “other” responses after coding.

Two analysts independently coded states’ activities. When the coding differed, the project description was discussed and consensus was reached. Coded data were then entered into a new Microsoft Excel spreadsheet.

The unit of analysis was the state for each grant period. For each state in a grant period, we coded the overall activities into 1 of the 4 categories (see Table 2, Supplemental Digital Content 2, available at: http://links.lww.com/JPHMP/A215, for a list of coding definitions):

1. Farmers market work present, at least one state-level action present: State-level actions are actions taken by the state health department that influence or support farmers market work across the state. This often involves working with state-level agencies or organizations, and has an intention to influence or implement state-wide farmers markets or farmers market programs. This may also be through doing state-wide support of local coalitions or local health departments to support farmers markets. Some of the resulting work may occur across a region in the state or several counties or communities in the state. For a “pilot program” to be included, it must be a state-wide program being tested in more than one location or community with a stated purpose of expansion.

2. Farmers market work present, no state-level actions present: State-level actions are not taking place when the actions are focused on working with one or more communities on farmers markets with no influence or collaboration with state-level policies, programs, or partners; no clear intention to influence or implement state-wide farmers markets or farmers market programs; or no clear state-wide efforts for supporting community-level action in farmers markets. The implementation of a “pilot program” in a single community is not a state-level action.

3. Farmers market work present, could not be determined if state-level actions present: The description of the actions is not clear enough to determine whether they are state- or community-level. More information would be needed to determine.

4. No farmers market work present.

The state data with at least 1 state-level farmers market action present were then coded for the presence of several items under 3 categories: topics, process, and partnerships. The presence of this item was recorded if it occurred at least once in a grant period; multiple instances of an activity were not counted. The final list of items under each category is shown below (see Table 2, Supplemental Digital Content 2, available at: http://links.lww.com/JPHMP/A215, for coding definitions of listed items).

• Topics: existing markets, incentive programs, land use policies, mobile markets, new markets, nutrition assistance benefit programs (SNAP/EBT, transportation, WIC Farmers Market Nutrition Program/Senior Farmers Market Nutrition Program/Cash Value Voucher), nutrition education, promotion/marketing, and transportation.

• Processes: assessment/evaluation, participating in a coalition, policy, providing funding, providing training and technical assistance, and supporting community action.

• Partnerships: coalitions, Department of Education, faith-based, not-for-profits, nutrition assistance benefit program offices, office on aging, SNAP-Education (SNAP-Ed), state Farmers Market Association, state or regional Department of Agriculture or agricultural extension, and universities/colleges.

Partnerships were only coded if the grantee discussed working directly with the SHD (not with a community within the state).

Results

State-level work

We reviewed the reports for the 3 cooperative agreements, and found that for 03022 (2003–2008), 19 of the 28 grantees (67.8%) reported working on farmers markets, and 7 of the 28 grantees (25.0%) reported state-level work (Figure 1). For CPPW (2010–2013), 13 of the 51 (25.5%) grantees reported working on farmers markets, and 6 of the 51 grantees (11.8%) reported state-level work. For 805 (2008–2013), 24 of the 25 grantees (96.0%) reported working on farmers markets and 14 of the 25 grantees (56.0%) reported state-level work.

FIGURE 1. Percentages of States Working on Farmers Markets Across State Programs Funded Out of DNPAOa.

^aFor cooperative agreement 03022, 19 of the 28 grantees (67.8%) reported working on farmers markets, and 7 of the 28 grantees (25.0%) reported state-level work. For cooperative agreement CPPW, 13 of 51 the (25.5%) grantees reported working on farmers markets, and 6 of the 51 grantees (11.8%) reported state-level work. For cooperative agreement 805, 24 out of the 25 grantees (96.0%) reported working on farmers markets, and 14 of the 25 grantees (56.0%) reported state-level work.

An example of state-level work in the 805 program was the Indiana Department of Nutrition and Physical Activity’s (DNPA) progress in increasing the number of farmers markets that accept SNAP benefits. In partnership with the Indiana Cooperative Development Center and Purdue Extension, DNPA created the EBT at Farmers Markets project, a state-wide initiative focused on increasing acceptance of SNAP benefits at farmers markets.

Several states reported farmers market work that was not considered state-level work. For example, as part of the 03022 program, the Colorado Department of Public Health and Environment provided funding to the Denver Urban Gardens’ Growing for Health project to support the Fairview Youth Farmers Market. Funding allowed the market to provide greater access to fruits and vegetables and nutrition education to urban populations in Denver, Colorado. The farmers market work described did not indicate influence or collaboration with state-level policies, programs, or partners, nor state-wide efforts for supporting community-level action.

Topics, processes, and partnerships

Across the state-level activities, the most common topics were work on existing markets, new markets, nutrition assistance benefit programs, and nutrition education (Figure 2). State-level promotion/marketing, incentive programs, and land-use policies were also implemented by several grantees.

FIGURE 2. Total Number of Grantees Reporting Topics in State-Level Work Across all Programsa.

^aExisting markets, n = 19; nutrition assistance benefit programs, n = 17; new markets, n = 15; nutrition education, n = 9; promotion/marketing, n = 6; incentive program, n = 3; land use policies, n = 3; mobile markets, n = 2; transportation, n = 2; and other topics, n = 5.

The most common processes discussed across the grantee reports when working on state-level farmers market activities were providing training and technical assistance, supporting community action, and providing funding (Figure 3). Other processes discussed were participating in a coalition, policy work, and assessment/evaluation.

FIGURE 3. Total Number of Grantees Reporting Processes in State-Level Work Across All Programsa.

^aSupporting community action, n = 16; providing training and technical assistance, n = 15; providing funding, n = 12; assessment/evaluation, n = 7; participating in a coalition, n = 5; and policy, n = 5.

There were a wide variety of partnerships discussed across the grantee reports. The most common were with nutrition assistance benefit program offices and state or regional Department of Agriculture or agricultural extension offices (Figure 4).

FIGURE 4. Total Number of Grantees Reporting Partnerships in State-Level Work Across All Programsa.

^aDepartment of Agriculture or agricultural extension, n = 9; nutrition assistance benefit program offices, n = 8; coalition, n = 5; not-for-profits, n = 5; Department of Education, n = 2; faith-based, n = 2; Office on Aging, n = 2; SNAP-Education, n = 2; State Farmers Market Association, n = 2; university/colleges, n = 2; and other partnerships, n = 7.

State examples

The following 2 examples demonstrate the common topics, processes, and partnerships presented by grantees in their submitted reports:

1. Under the 805 program, the Michigan Department of Community Health (MDCH) provided training and technical assistance, funding, and supported community action through the Building Healthy Communities Project. With MDCH support, local coalitions made efforts to increase the availability of healthy foods by establishing new farmers markets or providing greater access to existing markets. Several of the Building Healthy Communities farmers markets offered nutrition education (such as cooking demonstrations) and utilized EBT machines to accept SNAP benefits.

2. In the CPPW program, the Alaska Department of Health and Social Services worked with several partners, including the Division of Agriculture, the University of Alaska Fairbanks Cooperative Extension Service, and the Division of Public Assistance to provide funding and training to 2 farmers markets to accept EBT cards through the Alaska Farmers Market-Quest (SNAP) Card Pilot Project. Because of the pilot program’s success in making healthy, local foods more accessible to low-income Alaskans, partners put funds toward grants for 6 additional markets across the state in 2012.

Discussion

This article describes some key roles of CDC-funded SHDs in supporting farmers markets since 2003. We identified common themes and activities, including working with existing markets, working on acceptance of nutrition assistance benefit programs, providing training and technical assistance, supporting community action, and partnering with nutrition assistance and agriculture. Findings from this study may generate ideas for other SHDs to implement future state-level strategies that can increase the reach of farmers market programs.

In the 03022 and 805 programs, the majority of states worked on farmers markets. The number and percentage of SHDs that engaged in at least one state-level action increased from 03022 to 805. Even with the smallest number of grantees, the 805 program had the largest number and percentage of grantees working on state-level farmers market work, with over 50% of 805 grantees taking on wide-reaching state-level farmers market work. The increase from 03022 to 805 may be attributed to DNPAO’s shift in focus from individual-level strategies to PSE change strategies around 2007 and 2008, which was reflected in the requirements and guidance given to grantees under the 805 program.

Some key themes emerged when we looked across the most cited topics, processes, and partnerships to better understand the SHD roles that can affect state-wide change for farmers markets. SHDs’ primary activities have been to support the work of existing markets and increase the acceptance of SNAP/EBT at these markets. Focusing on existing markets more than new markets may be attributed to the resource intensity needed to develop new markets, particularly in low-income communities, such as funding for start-up costs, recruitment of a sufficient number of farmers, hiring a market manager, and creation of a volunteer support base to help run the market.^20,21 Enhancing existing markets, which already have some infrastructure in place, may be viewed by SHDs as a better use of limited public health funds. In addition, increasing affordability of healthy foods through increased acceptance of nutrition assistance benefit programs is often a function of public health and is a logical place for public health practitioners to focus their efforts.

To implement farmers market activities across the state, grantees most often provided technical assistance and training, and supported community action on farmers markets. SHDs are well-positioned to provide technical assistance, training, and potential funding to local health departments across the state, and can develop guidance, tools, and resources to help local health departments implement common strategies. In addition, technical assistance and training provided by SHDs is a method for obtaining broader reach with limited dollars.

Common partners were the state or regional Department of Agriculture or agricultural extension and the nutrition assistance benefit program offices, both key groups that work in the arena of farmers markets and SNAP/WIC. The partnerships with the agricultural sector are important as farmers market programs are predominantly supported through agricultural partners, in an effort to help support local farming economies. It was surprising that only 2 SHDs partnered with state farmers market associations, as these groups are intended to be a resource for farmers markets in the states they serve. Currently, 27 states have farmers market associations (J. O. Cheek, MUEP, oral and e-mail communication, June 2015). This number has increased over time and is continuing to grow, so this is an emerging partnership opportunity for SHDs. In addition, in the future there could be increasing partnerships with SNAP-Ed, as the recent guidance to state SNAP-Ed administrative and implementing agencies encourages evidence-based policy, system, and environmental strategies and interventions to support obesity prevention, with farmers markets listed as a potential strategy.²²

An understanding of common roles, activities, and partnerships across SHDs can offer funding organizations and other states ideas for implementation of future state-level work. Depending on a state’s context, they may want to focus on key state-level partnerships that result in changes or actions affecting farmers markets across the state, or ways to provide financial and technical assistance to communities across a state in their farmers market work. If connections are not already being made in a state, organizations working on farmers market programs in their state but not funded by CDC (such as departments of agriculture, hunger organizations, or nutrition assistance programs) could consider reaching out to public health practitioners focused on nutrition and obesity prevention for possible partnerships, synergy, and maximizing use of federal funds.

Several limitations to this study should be noted. The reports reviewed were all self-reported and had varied levels of detail and descriptions. This is evidenced by the number of states in which the level of farmers market work could not be determined. Second, the cooperative agreements had different guidance and funding amounts, so there may have been necessary differences in the types and levels of grantee activities. Third, restrictions on spending of federal funds could inherently limit some activities. Lastly, because of limited data and lack of funding for in-depth evaluations of these programs, we were unable to assess the level of impact of various state activities and partnerships for farmers markets. This may be an important next step for efforts supporting and evaluating farmers market work.

In summary, we provide a broader base for the literature on the roles SHDs can play in supporting farmers markets across a state, including the topics, processes, and partnerships involved. These findings can inform future planning at the state and federal levels on environment, policy, and systems approaches that improve the food environment through farmers markets.

Implications for Policy & Practice.

This study provides a broader base for the literature on the roles state health departments can play in supporting farmers markets across a state, including the topics, processes, and partnerships involved. The common farmers market policies and practices identified in this study, such as working on nutrition assistance benefit programs, incentive programs, and land-use policies, and common partners, such as nutrition assistance benefit program offices and state or regional Department of Agriculture or agricultural extension, can be adopted as strategies when developing future policy and practice work. These practice and evidence-based strategies can serve as a model for state-level public health practitioners seeking to implement similar farmers market activities in “real-world” settings.