Healthy Food Incentive Programs: Findings From Food Insecurity Nutrition Incentive Programs Across the United States

Participant Recruitment

Qualitative data were collected on HFI programs across the United States—specifically from 2015 to 2016 recipients of FINI-funded multiyear community-based projects and large-scale projects. In 2018, 22 interviews across 19 grantee organizations were conducted (selected for project size, geography, etc.). In terms of regions represented, interviewees included 22% from the Northeast, 17% from the South, 13% from the Midwest, and 48% from the West. Grant year was about half in 2015 (42%) and half in 2016 (58%), while large-scale projects comprised 47% of interviewees and 53% were community-based projects. Additionally, eight interviews with FINI stakeholders were conducted to better understand policy implications. Stakeholders were identified by the research team using a snowball sampling method and included representation across policy advocates, academicians, federal employees, and technical assistance (TA) providers. Interviews were conducted by telephone and in-person when possible (e.g., when interviewees and authors coincided at meetings).

Semistructured Interviews

The semistructured interview guide was developed by the authors and explored the following topics: (1) best practices and promising findings, (2) policy implications, and (3) knowledge gaps and opportunities. Interviews were conducted by three trained researchers by phone interviews, mostly one-on-one, but some with multiple interviewees from a single FINI project. The interviews were iterative, probes and questions were tailored to each interview, and the guide was modified as appropriate throughout the interview process. This study was approved by the University of Nebraska Medical Center Institutional Review Board. Verbal consent was obtained from all interviewees.

Data Analysis

All 38 interviewees (across 30 interviews) provided verbal consent to participate and be audio-recorded; interviews were transcribed verbatim. Thematic content analysis (Patton, 2002) was used within NVivo qualitative software (QSR International, 2018). An initial code list was developed with input from all authors, and several transcripts were coded by multiple coders to establish reliability between coders and reach consensus on disagreements. Next, each transcript was coded for meaning units by one of four authors. Emergent themes were identified through frequency of coding within similar contexts and across interviews. Our thematic content analysis was driven by a priori theoretical understanding of HFI programs and the design of the semistructured interview guide. Thus, themes were common across most interviews, given the structure of the guide and the interest in specific program characteristics. Finally, results were validated by having external experts review reported findings to ensure themes were adequately captured.

Range of Projects and Scope

Diversity in project implementation included types of retail outlets, geographic focus, redemption methods, and incentive match amounts (Table 1). Some programs provided a dollar-for-dollar incentive match, commonly up to $20 per visit; others provided incentives for purchases on the next visit, while others included an immediate incentive. Incentives also varied slightly in terms of what items could be purchased using the incentive: some only on locally grown FVs, some only on fresh FVs, and some included canned and frozen FVs without added sugars. Loyalty cards were used in grocery stores and could provide automatic discounts or be redeemed on subsequent visit(s). Program rules also specified which products were eligible for earning and redeeming incentives. Many programs allowed participants to earn incentives with the purchase of locally grown FVs and redeem incentives on any type of FV. One interviewee described the nuance of how their incentive program operates:

Double-Up is only for [locally] grown produce. Most produce sold at the farmers markets is inevitably local, but we do have some vendors that might bring in produce from elsewhere, and they’re pretty clear on labeling which products are and are not eligible. (first column in Figure 1)

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Table 1

Program Characteristics and Types of Variations

Program Characteristic	Types of Variations
Retail food outlet	• Farmers markets
	• Grocery stores
	• Corner stores
	• Food co-ops
	• Farm stands
	• Mobile markets
	• Community-supported agriculture
Geographic focus	• City or town
	• Statewide
	• Regional
	• Multisite across the United States
Methods for distribution and redemption	• Tokens
	• Loyalty cards
	• Paper coupons or vouchers
	• Automatic discounts
	• Coupons printed on receipts
Amount of incentive match	• Dollar-for-dollar up to a certain amount (e.g., $20 per visit)
	• Matches at different ratios (e.g., 40%, 50%)

Program Benefits

Interviewees emphasized the overwhelmingly positive impacts of FINI, typically describing the FINI program in terms of the potential for “a trifecta of benefits.” Perceived strengths of FINI programs cut across three umbrella areas (second column in Figure 1).

Program Promotion and Awareness

Interviewees reported a wide assortment of strategies for promoting their HFI programs and creating awareness and buy-in among an often “hard-to-reach” population. Some best practices for promotion of the FINI program that interviewees mentioned included on-site signage; social media; TV, radio, bus, and train ads; and billboards. For some grantees, it was often necessary to translate materials into other languages to reach diverse consumers.

Traditional advertising (e.g., signage, TV, radio) were utilized and viewed as helpful, yet many participants reported hearing about FINI through word of mouth, including via ambassadors, described as community members with firsthand experience using incentives. Some grantees recounted holding trainings for employees of partner organizations to equip them with background knowledge. Community partners also oversaw venues to promote HFI programs (e.g., food pantries). One participant described their range of promotion strategies employed, “Mass media was helpful to raise awareness in the first two years. As far as who is showing up at the market, we found the best resource is word of mouth” (third column in Figure 1).

Community-Based Partnerships

Various community-based partnerships helped to advance FINI in terms of program promotion and awareness as well as facilitating program implementation. Agencies serving low-income individuals and health agencies were identified as valuable community-based partnerships that worked synergistically with FINI programs. These partners included local social service providers, which were effective given the existing relationships with the target audiences. Interviewees emphasized that ensuring case workers and other direct service staff were knowledgeable about FINI was effective in generating program awareness.

Interviewees collaborated with community partners such as food banks/pantries, schools, health care organizations, federal food assistance programs (e.g., SNAP, WIC [women, infants, and children]), nonprofits, and other social service agencies. Some SNAP agencies disseminated program information to eligible households through direct mailers, while others described barriers such as privacy and resource constraints. SNAP-Ed sometimes took a more involved “on-the-ground” role, helping lead coordination with program sites to be equipped to offer FINI programs (e.g., setting up EBT [electronic benefit transfer]) and promotion onsite through cooking demonstrations. One interviewee described the role that SNAP-Ed plays with their program, “We are working with our SNAP-Ed agency here to get incentive information out in the hands of SNAP clients whenever they come into the community service offices. They’re equipping their call centers with information about these programs as well.” Conversely, there were many states with limited SNAP-Ed budgets, and thus other partners (e.g., Cooking Matters) helped fill this role (fourth column in Figure 1).

Interviewees described ways in which health departments contributed to FINI programs, sometimes as the entity that operated and led the program; alternatively, health departments sometimes served as an anchor for the program and a connector to other agencies. Health care providers (e.g., pharmacists, primary care) were also an avenue to introduce individuals to FINI programs.

Technical Assistance and Peer Interactions

Most interviewees indicated that they received TA from leaders in the area of food access (e.g., Fair Food Network, Wholesome Wave). TA was typically provided for those just starting work in HFI or “scaling up” existing programs. Specific TA received included grant application development, branding, working with various food retail outlets, implementation, and measurement/evaluation. Existing, “ready-to-use” branded materials helped when programs were launching. One interviewee described how these tools were helpful, “The program is rolled out fast and furious. Having materials was helpful in the first year. We’ve [subsequently] moved away from original design, but still like the logo so there’s consistency with the rest of the nation.”

TA that helped promote collaboration with various food retail outlets included sharing best practices in working with food retail outlets, point-of-sale (POS) systems, and training for retail staff. TA providers also convened FINI recipients through bimonthly phone calls, webinars, a Web portal with resources, and annual convenings. Interviewees underscored the value of these peer interactions, with one interviewee citing, “The summits are extremely valuable and created a nationwide support network. I know people across the country doing this work, and we’re in constant communication.” A strong desire for more information sharing, from both peers and experts, was described (fifth column in Figure 1).

Measurement and Evaluation

Across all FINI programs, the goal was to demonstrate effectiveness, reach, and process for implementation in order to translate programs to other settings and leverage resources for policy change and sustainability. Interviews revealed a range of what aspects were being assessed and rigor of evaluations. Outcomes that interviewees indicated were important to their programs included redemption rates across site types, sales and volume of FVs distributed through incentives, consumer-level outcomes (e.g., dietary patterns), impact on local economy (e.g., multiplier effect), impact on farmers and retailers, and demand for local foods. As FINI programs are implemented across the country, sharing best practices and valid and reliable measurement tools is a need that could be addressed through TA and coordination across FINI grantees. One interviewee described how they pieced together their evaluation, “Our evaluation was a little ad hoc. There are a lot of different models out there, I think one of the things that FINI helped with is streamlining and sharing techniques” (sixth column in Figure 1).

Program Challenges

HFI programs are a novel approach to promoting healthier diets among low-income consumers and are still evolving. Interviewees reported some nuanced challenges with reaching low-income populations across their geographic regions. At all location types, potential stigma against SNAP benefits and incentives being used created a hurdle that was best addressed through education and continued implementation for stakeholders to recognize multiple benefits for the community. One interviewee described the need to overcome stigma, “There’s perceptions about farmers markets not being for everybody. That they’re for certain demographics’ income levels. So working against some of those narratives.” FINI programs were also occurring in the “real world,” and sites where incentives were offered were not always the primary food shopping location for low-income populations. This also meant that some program sites had to develop new strategies for incorporating more local FVs, as well as managing placement, promotion, and shelf life.

Several challenges were also identified when working with various retail food outlets, including implementation, tracking, and distribution and sourcing of local FVs. One barrier commonly cited was working with existing technology and POS systems. As Table 1 describes, distribution methods included loyalty cards, coupons, or automatic discounts. If a retail outlet had an older POS system, the burden was on FINI grantees to find technology solutions. An interviewee described this challenge, “They’ve changed to a different POS system, which has less flexibility. The system could not recognize an EBT customer in real time and a program had to be written to capture transactions” (seventh column in Figure 1).

Future Directions and Recommendations

All interviewees provided recommendations to help improve their own specific programs, as well as increase traction and synergy between programs across the U.S. Grantees were asked to summarize messages intended for policy makers. The “trifecta of benefits” was reiterated, stressing that the multitude of positive outcomes could be tailored to interests of particular policy makers and audiences. One interviewee stressed the value of stimulating local economies, “It’s important to communicate to policy makers the return on investment of FINI. There is value in keeping those dollars local, the potential for job creation and supporting your neighbor.”

Most grantees mentioned sustainability of funding as an area they are actively working to address. As programs matured and, in some cases, received multiple years of FINI funding, some interviewees mentioned efforts to gain support from state legislation in order to secure dedicated funds for their HFI programs. One interviewee described transition to state-level support, “We are trying to pass state legislation that will dedicate funds to sustain the program, and nurturing relationships with cash match partners to keep them at the table.”

One key lesson learned was that broader food assistance policies (i.e., SNAP operations) tend to dovetail with HFI programs. To promote and sustain HFI programs, interviewees stressed the importance of communicating to policy makers with varying messages that may resonate with different audiences. These messages can be tailored to include benefits for farmers and food retailers, stimulating the local economy, low-income consumers improving diet and health, and supporting local food systems. Finally, HFI programs expand access to fresh FVs for low-income families, as one interviewee described, “[Low-income families] fall into habits of crisis eating (i.e., eating the cheapest foods), which are not the healthiest. Being able to access fresh produce does result in diet and health changes” (eighth column in Figure 1).