An Assessment of Perceived Barriers to Farmers Market Access in Washington State

Abstract

Objective

To explore if 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

400 SNAP participants, 51 SNAP-Ed Stakeholders.

Main Outcome Measures

SNAP participants’ reported barriers to accessing FMs, SNAP-Ed Stakeholders’ perceptions of FM access barriers.

Analysis

Thematic content analysis, descriptive statistics, two-sample tests of proportion, Pearson’s chi square tests, P<0.025

Results

A majority of SNAP participants reported they do not shop at a FM because it is inconvenient (n=193, 51%) and not financially viable (n=84, 22%). Nine percent (n=34) of SNAP participants stated that they experienced no barriers. SNAP-Ed Stakeholders placed an increased emphasis on transportation and cost barriers compared to SNAP participants.

Conclusions and Implications

Comprehensive, multi-level 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 help address financial and awareness barriers.

INTRODUCTION

Most Americans fail to meet recommended fruit and vegetable (FV) intake established by the Dietary Guidelines for Americans.¹ Evidence suggests higher socioeconomic status is associated with better dietary quality, including consumption of FVs,² and that lower-income adults are more likely to suffer from chronic disease³ and to rate their health more poorly compared to higher-income individuals.⁴

To help alleviate hunger and improve the nutrition of low-income households, the United States Department of Agriculture’s (USDA) Supplemental Nutrition Assistance Program (SNAP) aims to increase the food purchasing power of low-income households.⁵ The federal government developed the complementary SNAP-Education (SNAP-Ed) grant program to address food insecurity by supporting evidence-based nutrition education and obesity prevention interventions.⁶ SNAP-Ed funded agencies are expected to use the Dietary Guidelines for Americans Social Ecological Model for Nutrition and Physical Activity Decisions (SEM)⁷ to develop comprehensive interventions that are relevant, motivational, and address constraining environmental and/or social factors, recognizing that all sectors of society, together, shape an individual’s food and activity choices.⁶ One example of a SNAP-Ed intervention is to make farmers markets (FMs) accessible to low-income populations.⁶ Strategies include advising existing FMs on the process for obtaining Electronic Benefits Transfer (EBT) machines to accept SNAP benefits, supporting FMs to provide financial incentives to purchase FVs at the FM,⁶ or providing FM tours to low-income shoppers who are unfamiliar with FMs.⁸ The goal of these strategies is to improve the nutrition of low-income households; evidence shows a positive association between shopping at a FM and daily consumption of FVs.^9,10,11

The number of FMs in the United States increased from fewer than 2,000 in 1994, to over 8,000 in 2013.¹² This increase coincided with a 52% increase in the number of SNAP households shopping at FMs from 2011 to 2014.¹³ However, the 2002 shift in SNAP benefits from paper coupons to EBT negatively affected FMs’ ability to accept SNAP benefits.¹² The federal government established grant programs in 2011 to assist with the acceptance of EBT at FMs,¹² but lack of EBT acceptance at FMs still poses a substantial barrier for low-income shoppers.¹⁴ Furthermore, FMs that accept EBT still experience limited SNAP shopping,¹⁵ indicating additional barriers to shopping at FMs for low-income shoppers that are not addressed by facilitating SNAP benefit usage at FMs. These barriers may include lack of convenience for SNAP shoppers, perceived higher prices, lack of awareness of EBT card acceptance^15,16,17 and of the existence of nearby FMs,^16,17,18,19 lack of transportation,^16,17 and cultural or language obstacles.^10,16,17 Approaches to address these barriers include building community partnerships to increase FM and EBT awareness,^11,17 facilitating and promoting SNAP incentive programs and EBT acceptance,^9,11,17 and offering nutrition education opportunities at FMs.^9,11,17

To date, our knowledge of barriers to FM shopping for individuals who receive SNAP benefits is limited to convenience samples of SNAP participants in urban areas. Furthermore, few studies have incorporated the perspective of SNAP-Ed Stakeholders (individuals or groups who are involved in work to increase access to FMs for SNAP participants). Without the perspective of SNAP-Ed Stakeholders, it is difficult to conclude if barriers expressed by SNAP participants stem from a true lack of FM access or from lack of awareness of existing programs in place to facilitate access to FMs. A comprehensive assessment of barriers that includes both perspectives offers greater insight about the degree to which SNAP-Ed programming addresses the actual barriers experienced by SNAP participants. The purpose of this study was to: 1) characterize the reported barriers of SNAP participants to shopping at FMs, and 2) examine if SNAP-Ed Stakeholders perceived these same barriers. This analysis is part of a larger study conducted by the University of Washington Center for Public Health Nutrition, the purpose of which was to describe Washington’s current SNAP-Ed FM access activities, and present the associations between Washington SNAP participants’ FM shopping patterns, experiences with SNAP-Ed activities, and their FV consumption.¹¹ Perceived barriers to shopping at FMs were captured, but not analyzed, in the parent study.

METHODS

Sampling and Recruitment

SNAP Participants

Records of all SNAP participants in Washington State, as managed by the state’s Department of Social and Health Services (DSHS), comprised the sampling frame. Researchers developed a multi-staged, clustered, random sample of SNAP participants stratified by potential exposure to FM access activities, rurality, and primary language. To stratify the sample by potential exposure to FM access activities, researchers analyzed fiscal year 2016 and 2017 Washington State SNAP-Ed contractor work plans to identify the counties with ongoing FM-related SNAP-Ed activities. They used the National Center for Health Statistics classification scheme²⁰ to classify counties as urban or rural and selected 13 counties to reflect a balance of rurality by exposure to SNAP-Ed programming, including nine counties with SNAP-Ed programming and four counties without. Researchers identified zip codes from these counties whose boundary was either two miles (in urban counties) or five miles (in rural counties) from a FM.^21,22 The research team entered into a data-sharing agreement and worked with DSHS to draw a clustered random sample of SNAP participants from DSHS’s SNAP Participant Database; DSHS sent the research team the names, preferred language, and contact information of 3,000 individuals who lived within the identified zip codes. The research team then stratified the sample into 80% English speaking and 20% Spanish speaking to reflect languages spoken in low-income households in Washington State.^23,24 This sampling method allowed for a random sample of SNAP participants with comparable access to FMs, but with varying degrees of potential access to SNAP-Ed funded activities and a range of rurality.

In August 2016, the researchers mailed an introductory letter and a study information sheet to 2,500 SNAP participants selected randomly from the full sample provided by DSHS. From September to November, trained research assistants recruited and surveyed SNAP participants via telephone, using DSHS records to obtain SNAP participants’ primary telephone numbers, which included both cell phones and landlines. The researchers called each SNAP participant a maximum of three times, and left voicemails when possible.

Eligibility criteria required that individuals received SNAP benefits at the time of the survey, spoke either English or Spanish, were at least 18 years of age, and were one of the household’s primary grocery shoppers.

SNAP-Ed Stakeholders

Study participants must have been involved in SNAP-Ed FM work in Washington State over the 2015 and/or 2016 FM seasons, hereafter referred to as Stakeholders. To develop the sample the researchers identified all leadership supporting SNAP-Ed FM access work at the Washington State DSHS, Washington’s SNAP-Ed administrating agency, as well as the Washington State Department of Health (WA DOH) and the Washington State University (WSU) Extension Program; the latter two were the state’s SNAP-Ed implementing agencies at the start of the study. The researchers examined all WA DOH SNAP-Ed contractor work plans to identify contractors engaged in FM work. In 2015, the research team identified 32 Stakeholders; from this initial list of Stakeholders, the researchers performed snowball sampling, asking each participant to provide the name and email of any additional individuals they knew of who were involved in SNAP-Ed FM work in Washington State. An additional 11 Stakeholders were identified through this method. The researchers repeated this process for the 2016 FM season and identified 19 additional Stakeholders. The researchers emailed all identified Stakeholders and arranged a phone interview for individuals who agreed to participate. The final sample of 62 Stakeholders consisted of SNAP-Ed Contractors; Regional Leads (coordinators of FM, food security, and nutrition stakeholders within their region); county- or state-level representatives for WA DOH, Washington State Farmers Market Association, and WSU Extension; and FM managers.

The Washington State Institutional Review Board approved this study (D-091415-H16.01).

Study Tools and Procedures

SNAP Participant Survey

The researchers developed the SNAP Participant Survey based on preliminary findings from the Key Stakeholder Interviews and a previous statewide farmers market manager online survey.¹¹ The survey consisted of a mix of multiple choice, Likert scale, dichotomous, and free response questions that were organized in the following categories: shopping behaviors, use of SNAP/EBT, FM activity participation, nutrition incentives, comfort shopping at FMs, FV consumption, attitudes towards health and diet, food security, and demographics. The survey was professionally translated into Spanish (Foundation for International Services, Inc, Edmonds, WA), reviewed for accuracy by a native Spanish speaker, and pilot-tested with 12 SNAP-eligible volunteers in English and Spanish prior to survey finalization and data collection. Participants who indicated Spanish as their preferred language were contacted and surveyed by a Spanish-speaking data collector. If a data collector contacted a participant and did not speak their preferred language, the participant could request to have the survey conducted in Spanish and/or English.

Survey demographic questions included self-identified gender, age, race, income, education, and employment status. Primary language was identified as “English” or “Spanish” based on the language in which the survey was conducted. Food security was assessed using a validated two-item screener that was developed for food security assessment in the U.S. context.²⁵

Distance to the nearest FM was assessed using rurality and reported time to travel to the nearest FM. Rurality was based on participant county of residence and categorized as “Large metropolitan,” “Medium metropolitan” or “Small/non-metropolitan.”²⁰ The researchers asked participants about their frequency of shopping at a FM in the last year.

To assess the major barriers among SNAP participants to using FMs, participants were asked “What would you say is the number one reason, if any, that keeps you from shopping at farmers markets?” To assess FM shopping experiences, participants were asked to respond, on Likert scales, to questions related to level of comfort, ease of navigating, welcoming atmosphere, affordability of FVs, and ease of using SNAP/EBT benefits at FMs. The researchers also provided participants with the opportunity to offer additional explanation.

Key Stakeholder Interviews

Document review and the USDA SNAP-Ed Evaluation Framework²⁶ informed the development of the Key Stakeholder semi-structured interview guide. Stakeholders were asked to describe their work during the 2015 and 2016 FM seasons to promote FM access for low-income populations, the successes and challenges they experienced in this work, and the barriers they thought low-income shoppers face in accessing FMs.

Data Analysis

Based on emerging themes, SNAP participant-reported barriers to shopping at FMs were grouped categorically as “convenience,” “financial,” “awareness,” “comfort,” and “other barriers.” Convenience barriers related to the inconvenience of shopping at FMs and included location of the nearest FM, transportation, operating times, and selection of produce compared to other grocery outlets. Financial barriers related to price, and availability of SNAP/EBT acceptance. Awareness barriers included forgetting about FMs as a place to buy produce, being unfamiliar with the location of FMs or how they work, and the poor advertisement of FMs. Comfort barriers included answers related to the difficulty of shopping at FMs once there.

Descriptive statistics (Stata version 14.2, College Station, TX, 2017) were used to explore the relationship between stated barriers to shopping at FMs to socioeconomic indicators, level of food security, proximity to nearest FM, and frequency of FM shopping. The sample had 77 clusters consisting of zip codes within geographic range of FMs.¹¹ Cluster-robust standard error estimators converge to the true standard errors as the number of clusters approaches infinity, and 50 or more clusters are typically large enough for accurate inference;²⁷ as such, the researchers did not formally account for clustering in the models.¹¹ Two-sample tests of proportion and Pearson’s chi square tests were performed to determine if any of these comparisons varied significantly. The criterion for statistical significance was set at P<0.05. The researchers applied a Bonferoni correction factor to account for multiple comparisons. Therefore, the criterion for statistical analysis was set at P<0.025. The researchers coded SNAP participants’ open-ended comments related to FM access and shopping and used content analysis to expand on answers to the closed-ended questions.

Key Stakeholder Interview transcripts were analyzed using Atlas.ti (version 7.5.18, Atlas.ti Scientific Software Development GmbH, Berlin, Germany, 2014). Three trained qualitative researchers developed a codebook based on the interview guide and emerging themes of the interviews and conducted the coding of interview transcripts. Researchers piloted the codebook, established reliability, and double coded 42% of the interviews. Discordant coding was resolved through discussion and, when required, consultation with the principal investigator. The analysis focused on key themes regarding significant challenges or barriers to improving FM access for low-income shoppers. Based on emerging themes, these were grouped as FM access challenges/barriers related to SNAP benefits/EBT, cost, SNAP participant awareness, transportation, level of comfort, and convenience. To aid in detecting patterns and comparing interview themes with survey data, results were summarized by assessing the frequency with which Stakeholders commented on each theme as a challenge to improving FM access.²⁸

RESULTS

SNAP Participant Survey

Of the 2,500 SNAP participants receiving letters about the study, 2,369 were called before reaching a predetermined goal of 400 completed surveys. The research team determined this number of surveys would allow for reasonable subsamples by language and geography while remaining within budgetary constraints, and resulted in a 25% response rate. A total of 684 SNAP participants were excluded due to incorrect contact information, and another 73 were excluded who did not meet study criteria. After the excluded individuals were removed from the sample, 21% refused to participate and 54% were not reachable after three call attempts.¹¹ Approximately half of the respondents who completed the survey had frequented a FM at least once during the most recent FM season. Respondent characteristics are summarized in Table 1. Compared to the overall Washington State SNAP participant population, respondents were more likely to be White,²⁹ have a lower-income, and be unemployed or have a disability.^30,31 Respondents were evenly distributed across large-, medium-, and small/non-metropolitan counties.

Table 1.

Washington State Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Participant Survey Characteristics. 2016

Characteristic	n(%)
Gender
Male	132 (33.2)
Female	266 (66.8)
Age, y
18–30	79 (19.8)
31–51	138 (34.5)
51–65	109 (27.3)
≥65	74 (18.5)
Race/ethnicity
Non-Hspanic white	254 (63.5)
Other	146(36.5)
Primary language
English	348 (87.0)
Spanish	52 (13.0)
Household income (dollars)
<15,000	257 (71.2)
15,000 to <25,000	76 (21.1)
≥25,000	28 (7.8)
Food securitya
Secure	92 (23.5)
Insecure	299 (76.5)
Employment
Not employed	167 (42 0)
Full-time	38 (9.5)
Part-time or seasonal	51 (12 8)
Retired	57 (14.3)
Disability	85 (21.4)
Education
Less than high school	74 (18.6)
High school	113 (28.4)
Some college	137 (34.4)
College or more	74 (18.6)
Rurality
Large metropolitan	130 (32.5)
Medium metropolitan	128 (32.0)
Small/nonmetropolitan	142 (35.5)
Distance to nearest farmers’ market, min
<10	151 (46.2)
11–20	112 (34.3)
≥ 20	64 (19.6)

^aFood security was assessed using a validated two-item screener.²⁴

Table 2 displays SNAP respondents’ reported top barriers to shopping at FMs. Over half (n=193, 51%) of SNAP respondents reported barriers of inconvenience, such as the need to make an “extra trip” to incorporate the FM into grocery shopping, limited days and hours of operation, relatively limited selection in comparison to grocery stores, and inconveniences related to traveling to and from FMs. Approximately one-fifth (n=84, 22%) reported financial barriers, including unaffordability and either the lack of or not knowing whether the FM accepted EBT. Other reported barriers included lack of knowledge of FMs’ purpose and operations (n=28, 8%), and lack of comfort when shopping at FMs (n=26, 7%). Nine percent of respondents (n=34) stated that they experienced no barriers to shopping at FMs.

Table 2.

Barriers to Shopping at FMs: SNAP Participants versus SNAP-Ed Stakeholders in Washington State

	SNAP Participants (n = 397)		SNAP-Ed Stakeholdersa (n = 61)
Data source	Survey question		Semistructured interview
	What would you say is the number 1 reason, if any that keeps you from shopping at FMs?		Comments related to significant challenges or barriers to improving FM access for low-income shoppers
Response	Answer	n(*)	Top 4 key emergent themes
	1. FMs are not convenient places to shop	193(50.9)	1. Lack of transportation was the most frequently stated barrier to improving access to FMs for low-income populations.  • Lack of reliable public transportation to get to FMs in a timely manner  • Difficulty in transporting perchases home
	• Limited hours of operation	63(16.6)
	• Cannot buy all groceries there	53(14.0)
	• Location of FM is nconvenient	49(12.9)
	• Lack of traroportation to get to FM	28(7.4)	2. Expense of FMs was the second most stated barrier.
	2. FMs are not financially viable	84(22.2)	• Perception among low-income shoppers that FMs have higher prices: however, incentive programs and acceptance of EBT make FMs a financially viable option  • FMs either do not accept EBT, or SNAP participants are not aware that they are able to use EBT at FMs
	• Produce is too expensive  • Cannot use SNAP/EBT	48(12.7) 36(9.5)
	3. Not aware of where and/or when FMs operate	28(7.7)
	4. Lack of comfort	26 (6.9)
	5. Other	14(3.7)	3. Limited days and hour of operation and processes to redeem SNAP benefits at FMs make shopping at FMs an inconvenient experience for low-income shoppers
	6. No barriers	34(9 0)
			4. FMs may be uncomfortable for low-income populations to shop at owing lo language barriers and not feeling welcome.

BT indicates Etectronic Benefits Transfer; FM, farmers’ markets; SNAP Supplemental Nutrition Assistance Program; SNAP-Ed, SNAP-Education.

^aIndividuals involved in work to increase access to FMs for low-income populations.

Some reported barriers to shopping at FMs varied significantly by sociodemographic characteristics, proximity to FMs, and frequency of FM use. Aggregate inconvenience barriers were more likely to be reported by respondents who were White (P<0.025) and who completed the survey in English (P<0.025). Participants who were under the age of 30 (P<0.025), reported a higher household income (<0.025), and were employed (P<0.001), were more likely to report hours of operation as a major barrier, while participants who lived greater than 20 minutes from their nearest FM were more likely to state location of the FM as their number one barrier (P<0.001). Lack of awareness of FMs was more likely to be reported by respondents who were screened as food secure (P<0.025). Respondents who reported no barriers shopped at FMs more frequently than those who did report barriers (P<0.001); respondents who reported lack of awareness of FMs shopped less frequently (P<0.01).

Most of the 197 respondents who had shopped at a FM reported positive experiences. A large majority (n=181, 92%) agreed that FMs are “comfortable,” (n=175, 89%) “easy to navigate,” (n=180, 91%) “welcoming to all,” and (n=160, 81%) “affordable.” Of the 62 respondents who had used their SNAP/EBT benefits at the FM, a large majority (n=55, 89%) agreed that it is easy to use SNAP/EBT at FMs. In response to open-ended questions, respondents referred to the community feel and friendliness of FMs; the trust in quality, organic, and/or fresh produce offered at FMs; the connection to the farmer and to where food is grown; the helpfulness of the staff and vendors; and the layout and open space to shop in. Approximately 10% of respondents commented on what makes FMs uncomfortable, including: the crowds at FMs, the lack of organization in comparison to grocery stores, difficulty in using SNAP benefits (e.g. need to “use the exact amount at the register,” the long lines to redeem benefits, difficulty in distinguishing SNAP eligibility of items), experiences of disrespect from the vendors or the feeling that FMs attract a “bourgeois crowd,” and lack of accommodations for persons with disabilities.

Key Stakeholder Interviews

Semi-structured interviews were conducted among a total of 51 Stakeholders from 35 organizations and 18 counties in Washington State. Although interviews occurred over two separate market seasons and included interviews from a diverse set of Stakeholders, answers were consistent across years, and thus were analyzed as a single dataset.

The most common barrier that Stakeholders perceived low-income shoppers as experiencing was a lack of transportation to FMs. Stakeholders stated that FMs are sometimes located in affluent areas, and felt low-income shoppers without reliable transportation may not be able to walk to FMs or easily transport purchases back home. As one Stakeholder stated:

“It's not just getting you from point A to point B… there are some buses that only allow you to bring so many bags of groceries with you, or so many products with you… so if somebody goes and gets a couple of bags of produce, that concern, it is going to be ‘can I take it on the bus?’”

Stakeholders also felt transportation barriers reduced the impact of other efforts to improve access to FMs (e.g., nutrition incentives). One Stakeholder commented:

“Transportation is a big issue because people who are on services don’t necessarily have cars, so they need to get to the places that they need to get to, and depending on what day of the week it is, will determine how they get there. So, like our Sunday market, which we did match… there’s no bus.”

Stakeholders felt that unaffordability and a lack of awareness that FMs accepted EBT inhibited low-income shoppers from accessing FMs. Many Stakeholders felt that SNAP participants mistakenly perceived FMs as expensive, and that with FM incentives and EBT, FMs were just as affordable as other produce retailers:

“... it’s not like they couldn’t afford it, because between WIC and [nutrition incentives] and EBT, they probably have enough to buy it, but they … probably for the value of their money, they feel like they could use more … use their EBT anyway at the grocery store better. But you get the $40 from WIC and you get the extra money from [nutrition incentives], you’re going to spend it there, but I think the barrier would be the feeling like it’s more expensive.”

Stakeholders additionally described the token-system currently in place for using EBT at most FMs as singling out low-income shoppers, setting them apart from the general population, and creating stigma around EBT use. One Stakeholder commented:

“…accepting EBT and doing the token is really not a fully, in my mind, a fully successful response, because people feel, other people know that I’m using tokens and that identifies me…so, what I think, successful EBT card use at a farmers market is for the vendors to take the EBT cards.”

Stakeholders worried that shopping at FMs was inconvenient and uncomfortable for low-income shoppers. Stakeholders commented that because of the limited days and hours of operation, FMs can be difficult to get to, and that because FMs do not provide the same one-stop-shop shopping environment as grocery stores, this may inhibit shoppers from incorporating FMs into their shopping routine. Stakeholders were concerned that the FM shopping process may be unpleasant for low-income shoppers, as they have to go to a number of different booths to receive nutrition incentives and to redeem their EBT. Stakeholders were additionally concerned about potential language barriers, and that SNAP participants may feel they do not belong at FMs.

“When they have to come to an information booth, or when they have to sign here, and sign here, and sign here, so I have to go to the WIC booth to get my check. And I have to go to the information booth to get my EBT. And then once I get my EBT, then I go to this person to get my [nutrition incentive]. And then I go to the Healthy Families Booth to get my extra bag of produce. It’s like holy-moley. Nobody else has to go through this except the low-income who struggle to get there anyway, and struggle to have the dollar.”

Stakeholders felt that a lack of awareness was a major barrier to FM access, and commented on their proposed and existing efforts to increase FM awareness. These included the use of community liaisons, promotion through events and services that target low-income populations, and the compilation of resources to inform targeted populations what and where FM services are available.

DISCUSSION

A majority of SNAP participants stated that their number one reason for not shopping at FMs was either (1) the inconvenience of shopping at FMs, or (2) the price of produce sold at FMs. Participant-reported barriers remained largely consistent across sociodemographic characteristics, although results did indicate some differences in barriers by age, race, language, economic status, and proximity to the nearest FM. Stakeholders identified many of the same barriers stated by SNAP participants, but Stakeholders’ interpretation of these barriers, as well as the emphasis they placed on transportation and cost barriers, differed from the barriers stated by SNAP participants (Table 2).

The findings from the SNAP Participant Survey are consistent with other studies, which have found that inconvenient location and limited market hours were among the major limitations to FM shopping among low-income and marginalized populations.^16,32,33 While some studies have found price and uncertainties regarding payment methods are barriers to FM access for this population,^32,33 Webber et. al. found that the convenience of attaining food was a primary concern for low-income shoppers, even if that meant paying a higher price for items.³⁴

A 2016 systematic review found that, among studies that specifically investigated facilitators and barriers of FM use among low-income populations, there was evidence that prices at FMs were considered to be fair and reasonable.¹⁶ Similarly, in this current study, financial barriers were not the most commonly stated barrier to shopping at FMs among SNAP participants, and results from the Key Stakeholder Interviews indicate that Stakeholders recognize that FMs are affordable for many low-income shoppers.

Results from the Key Stakeholder Interviews indicate that there may be misconceptions regarding the most prevalent barriers experienced by SNAP participants, including their belief that lack of transportation was a major barrier to accessing FMs and their limited recognition of inconvenient FM operating times, both of which are inconsistent with the SNAP Participant Survey results and current literature.^16,32,33,34 In 2012, Washington SNAP-Ed began to encourage SNAP-Ed contractors to plan and conduct policy, systems, and environmental (PSE) changes in FM settings with the goal of equitable access for all shoppers. A recent review of Washington State SNAP-Ed FM initiatives indicated that these efforts are associated with SNAP participants’ FM shopping and FV consumption;¹¹ however, Washington SNAP-Ed contractors’ and their partners’ continued efforts to develop, support, and implement strategies that make it easier for low-income families to shop at FMs may be strengthened by concentrating their resources on the most prevalent barriers to shopping at FMs as reported by SNAP participants.

Study limitations include disproportionate representation of SNAP participants who identified as White compared to the general Washington State SNAP population. As such, there may be cultural barriers that this study did not adequately capture. Additionally, SNAP participants were only asked to state their number one reason for not shopping at FMs. Thus, data do not capture additional barriers that may exist even if major barriers are appropriately addressed. Due to the various methods of data collection for the SNAP Participant Survey and the Key Stakeholder Interviews, emerging themes from the two data sets were not completely aligned and a quantifiable comparison was not feasible between these two groups; rather the qualitative results from the Key Stakeholder Interviews were used to provide insight into current challenges to FM access from the perspective of those working to increase access to FM for low-income populations.

Considering the variety of stated barriers to FM access among SNAP participants, comprehensive strategies that address multiple levels of the social ecological model may be most effective at increasing SNAP use at FMs.⁵ Evidence shows that implementing multiple changes at various levels of the model is effective in improving eating behaviors, and that support and active engagement from various segments of society are necessary to induce individual behavior change.⁷ Strategies should focus not only on the individual, but also take into consideration how local policies, systems, and environmental factors influence individual behavior.⁶

IMPLICATIONS FOR RESEARCH AND PRACTICE

Findings from this study include the perspectives of market managers, service providers, and food access professionals, as well as low-income shoppers themselves, to provide a comprehensive analysis of current barriers to FM access. To address some of the identified barriers, priority considerations for new FMs could include maintaining variable operating times throughout the week, and locations that allow targeted populations to shop at as part of their normal routines. Targeted promotion of FMs in multiple languages, and more directed information regarding the existence of FM incentive programs and SNAP/EBT acceptance may also prove beneficial. Marketing and outreach efforts to reach more diverse populations may need to be expanded through community engagement and formation of new partnerships. Future work should aim to capture all barriers SNAP participants experience to shopping at FMs, not only their primary barrier. Current programming and future work plans to increase access to FMs should be evaluated on how well they align with the experiences of participants.

Findings from this study can be used to expand and strengthen public health and FM interventions by informing targeted focus on the most pressing barriers and challenges. Particularly as efforts aim to address all levels of the social ecological perspective - from individuals’ awareness to broader system changes – this research team indicates that interventions should be informed by a broad array of stakeholder perspectives, as well as the perspectives of the targeted population.