This group will receive routine services provided by WIC and an intervention that will combine behaviorally-focused nutrition education with 1) the establishment of a WIC-based farmers' market (implemented in 2019 during the WIC Farmers' Market Nutrition Program voucher issuance period \[June 19 to August 19\]), and 2) monthly trips to an area farmers' market (between September 1, 2019 and November 30, 2019 \[the end of the local growing season\]).

This group will receive routine services provided by WIC only.

Behaviorally-focused intervention grounded in the Social Ecological Model and Social Cognitive Theory to promote vegetable intake and the redemption of seasonal Farmers' Market Nutrition Program vouchers and monthly Cash Value Vouchers at farmers' markets.

Multilevel Behavioral Intervention

Jennifer Di Noia, PhD

Whole grains, non-starchy vegetables, fruit, and beans are a consistent feature of diets associated with a lower risk of cancer and other diet-related diseases. For cancer risk reduction, the American Cancer Society recommendation is to consume at least 2.5 cups of a variety of fruits and vegetables daily. Other than dietary choices, weight control and physical activity levels are important modifiable determinants of cancer risk. This study finalized a novel, theory-driven farm-to-WIC intervention developed in preliminary work to promote vegetable intake among low-income adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). In New Jersey (the location of the study), WIC provides participants up to $30 in seasonal Farmers' Market Nutrition Program (FMNP) vouchers and monthly cash value vouchers or CVV (valued at $11 for adults and $8 for children at the time of the study) redeemable at farmers' markets. The program combined behaviorally focused nutrition education with the establishment of a WIC-based farmers' market (implemented in the summer of 2019 during the FMNP voucher issuance period). Content to address other modifiable determinants of cancer risk was added. To create additional opportunities for experiential and hands-on learning, monthly trips to an area farmers' market were held (between September 1, 2019 \[after the WIC-based market was discontinued\] and November 30, 2019 \[the end of the local growing season\]). The research employed an experimental design to initially test the intervention in 3 WIC agency sites (1 intervention and 2 control sites) with 297 urban, primarily Hispanic adults. Program effects on primary outcomes of vegetable intake (measured objectively using dermal carotenoids as a biomarker of intake and via self-report) and FMNP voucher redemption (objectively assessed using data provided by WIC) were examined at mid- and post-intervention (3 and 6 months post-baseline, respectively). Intervention effects on potential hypothesized mediators and the redemption of CVV at farmers' markets, participant satisfaction with the program, and the cost-effectiveness of the intervention also were examined.

WIC-Based Intervention to Promote Healthy Eating Among Low-Income Mothers

Objectively assessed using data provided by the collaborating WIC agency. WIC reported whether participants redeemed any cash value vouchers at farmers' markets (yes or no) between baseline and 6 months.

Assessed via a single item (the Overall Satisfaction Rating Measure) querying how satisfied intervention recipients were with the intervention (on a 7-point scale ranging from very dissatisfied to very satisfied). Scores can range from 1 to 7. Higher scores represent a better outcome (greater overall satisfaction).

Assessed with a 5-item measure developed by the investigators querying how satisfied intervention recipients were with the intervention. Item responses were on a 7-point scale ranging from strongly disagree to strongly agree. Scores were averaged across items to derive a total score. Scores can range from 1 to7. Higher scores represent a better outcome (greater satisfaction with the intervention).

Vegetable intake was objectively assessed using a reflection spectroscopy device (the Veggie Meter) to measure the level of carotenoid pigments in participants' skin (scores can range from 0 to 800). Higher scores indicate a better outcomes (higher carotenoid levels).

Assessed with one of two items in a screening instrument developed by the National Cancer Institute. Participants reported the number of cups of vegetables (including 100% vegetable juice) they ate or drank each day (range 0-7). Higher numbers represent a better outcome (higher cups/day of vegetables consumed).

Objectively assessed using data provided by the collaborating WIC agency. WIC reported whether participants redeemed any FMNP vouchers (yes or no) from baseline to 6 months.

Assessed via self-report with an item from the National Cancer Institute's Food, Attitudes, and Behaviors (FAB) survey. Based on their responses, participants were classified as knowledgeable of the recommended cups per day (yes or no).

Assessed with items from the Healthy Home Survey. Participants reported the number of fresh, frozen, and canned vegetables they had at home. Responses were summed across items to derive a total score (range 0-23). Higher scores indicate a better outcome (a higher number of vegetables at home).

Assessed with items from the Healthy Home Survey. Participants reported the number of fresh, frozen, and canned vegetables they had at home. The number of different (unique) vegetables reported was summed across items to derive a total score (range 0-21). Higher scores indicate a better outcome (a greater variety of vegetables at home).

Assessed with items from the Healthy Home Survey. Participants reported the number of fresh, frozen, and canned vegetables they had at home. The number of different (unique) vegetables reported was summed to derive a total score (range 0-21). Higher scores indicate a better outcome (a greater variety of vegetables at home).

Assessed with a single item (the Preference Rating Measure) querying overall, how much the participant likes the taste of vegetables (on a 7-point scale ranging from not at all to a lot). Scores can range from 1 to 7. Higher scores represent a better outcome (stronger vegetable taste preferences).

Assessed via items from the Eating Among Teens and Young Adults Study (EAT)-II Survey (Laska et al., 2011). Participants reported how often, in the past month, they 1) bought fresh vegetables, 2) prepared a vegetable salad, and 3) prepared a dinner with vegetables. Responses were on a 5-point scale ranging from never to more than once a week. Ratings were summed across items to derive a total score. Scores can range from 1 to 15. Higher scores represent a better outcome (frequent use of the practices).

Assessed via a single item (the Preparation Skills Rating Measure) querying how the participant would rate his or her overall skill in preparing vegetables (on a 7-point scale ranging from poor to excellent). Scores can range from 1 to 7. Higher scores represent a better outcome (greater vegetable preparation skills).

Assessed via a single item (the Social Support Rating Measure) querying how much others support the participant to consume vegetables (on a 7-point scale ranging from not at all to a lot). Scores can range from 1 to 7. Higher scores represent a better outcome (greater social support for vegetable consumption).

Assessed with a validated measure used to evaluate the Stellar Farmers' Market program (Dannefer et al., 2015). Participants rated how much they agreed or disagreed with statements designed to measure confidence in the ability to prepare and consume fresh produce. Item ratings are on a 4-point scale ranging from strongly disagree (1) to strongly agree (4). Ratings were summed across items to derive a total score. Scores can range from 5 to 20. Higher scores represent a better outcome (greater self-efficacy for vegetable consumption).

Height and weight were measured by trained research staff with participants wearing light clothing without shoes. Body mass index was calculated as weight in kilograms divided by height in square meters.

Assessed with a validated 2-item measure (the Brief Physical Activity Assessment Tool or BPAAT \[Marshall et al., 2005\]). The instrument consists of two questions, one that assesses the frequency and duration of vigorous intensity physical activity and one that assesses the frequency and duration of moderate intensity physical activity undertaken in a usual week. A scoring algorithm is used to derive a total score (scores can range from 0 to 8). Participants are classified as meeting current physical activity guidelines (yes or no) based on the scores (a score greater than or equal to 4 indicates that the participant is meeting current physical activity guidelines, whereas a score between 0 and 3 indicates that the participant is not).

Assessed with a validated 2-item measure (the Brief Physical Activity Assessment Tool or BPAAT \[Marshall et al., 2005\]). The instrument consists of two questions, one that assesses the frequency and duration of vigorous intensity physical activity and one that assesses the frequency and duration of moderate intensity physical activity undertaken in a usual week. A scoring algorithm is used to derive a total score (scores can range from 0 to 8). Participants are classified as meeting current physical activity guidelines (yes/no) based on the scores (a score greater than or equal to 4 indicates that the participant is meeting current physical activity guidelines, whereas a score between 0 and 3 indicates that the participant is not).

William Paterson University of New Jersey

Professor, Department of Sociology

This group will receive routine services provided by WIC and an intervention that will combine behaviorally-focused nutrition education with 1) the establishment of a WIC-based farmers' market (implemented in 2019 during the WIC Farmers' Market Nutrition Program voucher issuance period \[June 19 to August 19\]), and 2) monthly trips to an area farmers' market and local supermarket (between September 1, 2019 and November 30, 2019 \[the end of the local growing season\]).

Multilevel Behavioral Intervention: Behaviorally-focused intervention grounded in the Social Ecological Model and Social Cognitive Theory to promote vegetable intake and the redemption of seasonal Farmers' Market Nutrition Program vouchers and monthly Cash Value Vouchers provided to WIC participants to purchase fruits and vegetables.

Intervention

Control

Total

Age, Continuous

Sex: Female, Male

Ethnicity (NIH/OMB)

Race (NIH/OMB)

United States

Region of Enrollment

Nativity

Place of birth was assessed in the subgroup of participants who were foreign-born (n = 209).

Place of Birth (Foreign-Born)

Language preference was assessed among the subgroup of participants who were foreign-born (n = 209).

Language Preference (Foreign-Born)

Years in U.S. was assessed in the subgroup of participants who were foreign-born (n = 209).

Years in U.S. (Foreign-Born)

Pregnancy Status

Breastfeeding Status

Educational Attainment

Car Ownership

Ease of borrowing a car was assessed among the subgroup of participants who did not own a car (n = 122).

Car Access: Ease of Borrowing a Car (If Not Owned)

How often can use car was assessed in the subgroup of participants who owned a car (n = 175).

Car Access: How Often Can Use Car (If Owned)

Supplement Use

Smoking Status

Past 7-Day Exposure to Secondhand Smoke

Food Security Status

Meeting Physical Activity Guidelines

Because weight and height were measured at the time of study entry, among pregnant participants, weight and height before pregnancy, and correspondingly, pre-pregnancy BMI could not be determined. Pregnant women (n = 54) were therefore excluded from analyses of BMI (analysis sample size= 242).

Body Mass Index

Based on their body mass index, participants were classified according to Centers for Disease Control and Prevention (CDC) weight status categories.

Because weight and height were measured at the time of study entry, among pregnant participants, weight and height before pregnancy, and correspondingly, pre-pregnancy BMI could not be determined. Pregnant women (n = 54) were therefore excluded from analyses of weight status (analysis sample size= 242).

Weight Status

Assessed with a 5-item measure of socially desirable response set (SDRS-5). Response options are on a 5 point scale ranging from definitely true (1) to definitely false (5). Extreme SDRS responses are scored 1, and all other responses are scored 0. Responses are summed across items to derive a total score (score range 0-5). Higher scores indicate a worse outcome (the tendency to give socially desirable responses on self-report measures).

Social Desirability Trait

Children in the Household Aged 2-5 Years

Vegetable intake was objectively assessed using a reflection spectroscopy device (the Veggie Meter) to measure the level of carotenoid pigments in participants' skin (scores can range from 0 to 800). Higher scores indicate a better outcome (higher carotenoid levels).

Vegetable Intake Carotenoid Scores

Self-Reported Vegetable Intake

Jennifer Di Noia, PhD, Principal Investigator

For vegetable intake carotenoid scores, analysis sample sizes were 137 in the intervention group and 124 in the control group. In the intervention group, 13 of the original 160 participants competed the baseline assessment only, 4 moved out of the area, and 6 discontinued their study involvement. In the control group, 10 of the original 137 participants completed the baseline assessment only, 2 moved out of the area, and 1 discontinued their study involvement).

Vegetable Intake Carotenoid Scores at 3 Months

For vegetable intake carotenoid scores, sample sizes were 137 in the intervention group and 124 in the control group. In the intervention group, 13 of the original 160 participants competed the baseline assessment only, 4 moved out of the area, and 6 discontinued their study involvement. In the control group, 10 of the original 137 participants completed the baseline assessment only, 2 moved out of the area, and 1 discontinued their study involvement.

Vegetable Intake Carotenoid Scores at 6 Months

Self-Reported Vegetable Intake at 3 Months

Self-Reported Vegetable Intake at 6 Months

Number of Participants Who Redeemed Any Farmers' Market Nutrition Program (FMNP) Vouchers at 6 Months

Knowledge of Vegetable Intake Recommendations at 3 Months

Knowledge of Vegetable Intake Recommendations at 6 Months

Home Vegetable Availability (Quantity) at 3 Months

Home Vegetable Availability (Quantity) at 6 Months

Home Vegetable Availability (Variety) at 3 Months

Home Vegetable Availability (Variety) at 6 Months

Vegetable Taste Preferences at 3 Months

Vegetable Taste Preferences at 6 Months

Vegetable Preparation Practices at 3 Months

Vegetable Preparation Practices at 6 Months

Vegetable Preparation Skills at 3 Months

Vegetable Preparation Skills at 6 Months

Social Support for Vegetable Consumption at 3 Months

Social Support for Vegetable Consumption at 6 Months

Self-efficacy for Vegetable Consumption at 3 Months

Self-efficacy for Vegetable Consumption at 6 Months

For weight status, sample sizes were 137 in the intervention group and 124 in the control group. In the intervention group, 13 of the original 160 participants competed the baseline assessment only, 4 moved out of the area, and 6 discontinued their study involvement. In the control group, 10 of the original 137 participants completed the baseline assessment only, 2 moved out of the area, and 1 discontinued their study involvement.

Body Mass Index at 3 Months

Body Mass Index at 6 Months

Number of Participants Who Met Physical Activity Guidelines at 3 Months

Number of Participants Who Met Physical Activity Guidelines at 6 Months

Number of Participants Who Redeemed Any Cash Value Vouchers or CVV at Farmers' Markets at 6 Months

Satisfaction was measured among the subgroup of participants who received the intervention (n = 160). Of this number, 128 completed the measure of overall satisfaction with program.

Overall Satisfaction With Intervention

Satisfaction was measured among the subgroup of participants who received the intervention (n = 160). Of this number, 128 completed the satisfaction measure.

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