The Impact of Financial Incentives on Fruit and Vegetable Expenditure and Consumption in Healthy Food Retail Environments: A Literature Review and Recommendations

Problem: In 2011, on average, U.S. adults and adolescents consumed produce fewer than two times per day (CDC, 2013). This dietary behavior is concerning as adequate fruit and vegetable intake is essential to maintaining a healthy weight (USDA, n.d.b, n.d.c), improving physical health (HSPH, n.d.), and preventing nearly half of the 10 leading causes of death in the United States (CDC, 2014; HSPH, n.d.). In numerous urban and rural communities across the country, inadequate produce consumption is rooted in unequal access to fresh fruits and vegetables (USDA, 2012a). Residents of these predominately low-income geographic areas must travel outside of their immediate neighborhoods to purchase high-quality, nutrient-dense food (USDA, 2012b). A highly touted response to this inequity has been to introduce or expand healthy food retail in low-access areas. While improving the physical availability of nutritious food is necessary, this action fails to address the other essential dimension of access: the affordability of healthy food at the consumer retail level. Background: A promising example of healthy food retail development is underway in New Orleans. In late 2014, Jake and Jake's will open a fresh food market in Central City-a neighborhood that has been characterized as a limited supermarket access area (TRF's LSA Mapping Tool, 2014) and food desert (Rose et al., 2009). To examine the health effects of the retailer's proposed programming, the City of New Orleans Health Department led a pilot health impact assessment referred to as the Myrtle Banks Redevelopment HIA. During my tenure as an MBR HIA data committee member, I commenced a literature review to assess the impact of financial incentives on consumer FV purchasing, FV consumption and venue patronage. Methods: Electronic literature searches in PubMed, Web of Science and the Cochrane Library, and supplementary hand searches were conducted to identify peer-reviewed, original research articles that evaluated the effectiveness of economic-incentive interventions in supermarket, grocery store or farmers' market settings. Google was used to identify pertinent grey literature. Sixteen original articles (on 15 studies) and one USDA interim research report, published between 1994 and 2014, were selected for critical review. Results: The majority of the financial-incentive investigations were conducted in chain supermarkets in France, New Zealand, the Netherlands, South Africa and the United States. The others occurred at U.S. farmers' markets. Low-SES individuals were the priority population in all but three investigations. The study incentives spanned discounts, rebates, matched funds, vouchers and coupons of different monetary values. FV expenditure and consumption: In a high percentage of studies, there was a statistically significant increase in FV purchases and consumption among subsidy recipients. Venue patronage: Produce subsidies seemed to induce first and repeat visits to a new food retailer among a substantial proportion of participants. However, only a small number of studies reported this data. Conclusion: Targeted financial subsidies increased fruit and vegetable purchasing and consumption among low-income grocery shoppers. This finding has important implications for healthy food retailers such as Jack and Jake's, policymakers, researchers and public health leaders. In communities with insufficient access to FVs, public health practitioners should catalyze or support formal efforts to assess the underlying issues and community readiness for change; and, where appropriate, contribute to the design, implementation and evaluation of intersectoral food-access campaigns.Master of Public Healt