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Objective This study evaluated the Michigan Farmers' Market Nutrition Program in one Michigan county to determine its effect on fruit and vegetable consumption behavior.
Design Education-only and coupon and education groups were randomly assigned; clinic appointment timing determined assignment to no-intervention and coupon-only groups.
Subjects/Setting Subjects were selected from WIC and Community Action Agency populations: 564 low income women completed the pretest; 455 completed the posttest. Attrition rate was 19.3%.
Intervention Subjects were assigned to one of 4 interventions: education about the use, storage and nutritional value of fruits and vegetables, distribution of farmers' market coupons, both education and coupons, or no intervention.
Results Both the education interventions and the coupon interventions had positive effects. Coupons had a direct effect on increasing fruit and vegetable consumption behavior but no effect on attitudes. Education had a direct effect on attitudes and seemed to exert an effect on consumption behavior through attitudes. The maximum impact of the intervention was achieved through a combination of education and coupons.
Main Outcome Measures A self-administered questionnaire before and after intervention measured attitudes about fruit and vegetable consumption and intake of fruits and vegetables. WIC records documented redemption of coupons.
Statistical Analyses Data analysis included 2-way multivariate analysis of covariance, univariate analysis of covariance, logistic regression, and covariance structure modeling.
Applications This study demonstrated that a low-income population may be more likely to increase its fruit and vegetable consumption behavior when incentives such as coupons improve affordability. J Am Diet Assoc. 2001;101:195-202.
Poor diet and physical inactivity are the 2 most powerful behavioral determinants of chronic disease for 75% of Michigan's population . Estimates from the 1996 Michigan Behavioral Risk Factor Survey (BRFS) indicate that only 26.4% of women with incomes less than $10,000 eat fruits and vegetables 5 or more times a day . Project FRESH (Farm Resources Encouraging and Supporting Health) is a Farmers' Market Nutrition Program of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) that provides fruit and vegetable coupons and education to WIC participants in addition to the regular food package.
There are few fruit and vegetable interventions in the low-income populations. One recent study of various WIC clinics throughout Maryland showed positive effects of a multidimensional, targeted, education-based intervention on fruit and vegetable consumption and various measures of attitudes and beliefs . Two evaluations have been published on the overall impact of Farmers' Market Nutrition Programs. The Connecticut Farmers' Market study found that subjects who received coupons were significantly more likely to use the farmers' markets than control subjects with no evidence of an effect on fruit and vegetable consumption . In Massachusetts, the Farmers' Market Coupon Program provided coupons and education to low-income elderly individuals . Change in food intake was not measured directly, but the authors suggested that purchase behavior indicated a possible increased consumption of fruits and vegetables.
This evaluation of Project FRESH sought to determine the effectiveness of fruit and vegetable coupons and education in changing fruit and vegetable consumption behavior among low-income women in one Michigan county. The study examined the effect of the program on attitudes about buying, preparing, and eating fruits and vegetables, redemption of coupons, and the number of fruit and vegetable servings consumed.
Intervention Population and Design
The intervention groups were selected from Genesee County, Mich., WIC and Community Action Agency Commodity Supplemental Food Program (CSFP) populations. Both of these metropolitan-Flint-area programs serve women and children at or below 185% of federal poverty income guidelines. The populations have similar demographic characteristics and are approximately 45% African-American. Informed consent was obtained in accordance with the Michigan Department of Community Health Human Subjects Committee.
Six hundred sixty-nine women attending routine WIC or CSFP appointments were recruited, with 564 (84.3%) completing the pretest, and 455 (80.7%, attrition 19.3%) returning to complete the posttest. Criteria specified that women were pregnant, lactating, or caring for young children, and eligible for Project FRESH due to nutritional risk. Four groups were compared: coupons and education, education only, coupons only, and no intervention. Due to the limitations of subject assignment in a clinical setting, it was not possible to randomly assign participants in all the study groups. During April and May participants were recruited at their WIC recertification appointments and randomly assigned to either the coupons and education or education-only group. The no intervention group was not randomly assigned but was recruited from women whose WIC clinic appointments occurred in June. Although the timing varied, recruitment procedures were identical for all WIC groups. The coupons-only group was recruited from CSFP i n June and also was not randomly assigned. The CSFP group recruitment was necessary because Project FRESH has a USDA-mandated education component, and a coupon intervention without education could not be administered to WIC clients.
Project FRESH coupons, redeemable for a total of $20 in produce from farmers' markets, are typically distributed in the early summer and remain valid in Michigan from June 1 through October 31. For this trial, pretest and posttest questionnaires were administered approximately 2 months apart, in June to July and August to September. To encourage participation, recruitment and data collection was coordinated with subjects' usual WIC and CSFP clinic appointments. Reminder postcards and telephone calls were used to increase follow-up rates and clarify missing data issues.
Coupons and cash incentives were provided for participation in data collection. The net worth of incentives varied slightly based on the recommendations of staff at CSFP and WIC. The coupons-only and coupons and education groups were given $20 in Project FRESH coupons after completing the pretest and received a cash incentive for the posttest 2 months later. The education-only and no-intervention groups received cash incentives at the pretest and were given coupons as incentives for completing the posttest 2 months later. The cash incentive was …