OBJECTIVES

The Farmer’s Market Nutrition Program (FMNP) provides fresh, locally grown fruits and vegetables (FV) to eligible participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). However, redemption of FMNP benefits remains low. This qualitative study explores facilitators and barriers to produce access and FMNP redemption for caregivers of WIC-eligible children in Philadelphia during the COVID-19 pandemic.

METHODS

We conducted semistructured phone interviews with caregivers between August and December 2020 to understand experiences with produce access and programming preferences to increase benefit redemption and produce consumption. We used content analysis with constant comparison with code interviews inductively and identified emerging themes through an iterative process.

RESULTS

Participants (n = 30) wanted their children to eat more produce but described barriers to produce access, including limited availability, higher cost, and limited time. The Supplemental Nutrition Assistance Program and WIC benefits improved the ability to purchase produce, but difficulties with electronic benefit transfer and pandemic-related office closures limited use of WIC benefits. Similarly, lack of convenient market locations and hours prohibited use of FMNP benefits. Caregivers described that an ideal food program would be delivery based, low cost, offer a variety of FV, and provide recipes and educational activities.

CONCLUSIONS

WIC-eligible caregivers want their children to eat more produce; however, they face multiple barriers in redeeming their benefits to access fresh produce. Delivery-based, low-cost produce programs may lead to increased produce access as well as benefit use. Future study is needed on feasibility and acceptability of produce delivery options among WIC-eligible families.

What’s Known on This Subject:

Rates of fruit and vegetable consumption are particularly poor among children from low-income families. Public assistance programs help improve produce access and increase food security among low-income populations. However, many of these programs go underused, including the Special Supplemental Nutrition Program for Women, Infants, and Children’s Farmer’s Market Nutrition Program.

What This Study Adds:

Little is known about contributors to low Farmer’s Market Nutrition Program redemption and experiences with produce access among Special Supplemental Nutrition Program for Women, Infants, and Children participants. Our study provides actionable feedback from caregivers on barriers to use of benefits and how to optimize benefit use and increase produce access.

The majority of children in the United States have insufficient intake of fruits and vegetables (FV), contributing to lifelong dietary patterns and poorer health outcomes.15  From 2007 to 2010, only 40% of children aged 1 to 18 years met US Department of Agriculture recommendations for daily fruit intake and a mere 7% met recommendations for daily vegetable intake.1  Eating patterns developed in childhood carry into adulthood and impact long-term health, underscoring the importance of early development of healthy eating behaviors.610 

Low intake of FV can be a sequela of food insecurity (FI)—the disruption of food intake or eating patterns because of lack of money and other resources—disproportionally affecting African American and Hispanic populations and contributing to the increasing incidence of obesity and chronic disease among children in these populations.1017  FI affected nearly 22% of children in Philadelphia in 2019, and rates worsened during the COVID-19 pandemic, with more than 40% of mothers with children younger than age 12 years reporting FI in April 2020.15,18 

Public assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), improve produce access and increase food security among low-income populations.19  African Americans and Hispanics account for more than one-half of all WIC participants, so programmatic changes in WIC have the potential to improve racial/ethnic disparities in both diet and obesity.16,17  However, these programs are often underused, with only 51% of those eligible in the United States participating in WIC in 2017.20  Further, only one-half of those who participate in WIC redeem Farmer’s Market Nutrition Program (FMNP) vouchers, which provide additional funds to purchase produce from farmer’s markets.2123  Redemption of FMNP vouchers is associated with higher FV intake; however, participation varies across states.2426  In Philadelphia, FMNP voucher redemption has been far below the national average of 55%; redemption rates were 26% in 2018 and plummeted to 17.5% in 2020 during the COVID-19 pandemic (Bureau of Food Assistance, Pennsylvania Department of Agriculture, unpublished data; 2018).23 

Little is known about contributors to low FMNP redemption and experiences with produce access among WIC participants, particularly during the COVID-19 pandemic. This qualitative study, conducted in partnership with the Philadelphia WIC program (N.O.R.T.H. Inc.), sought to explore facilitators and barriers to (1) intake of FV among WIC-eligible families, (2) use of available food benefits, specifically the FMNP, and (3) understand caregiver preferences for programs aimed at increasing produce consumption. Through direct community feedback, we aimed to elucidate actionable steps to improve produce access and food benefit use among WIC-eligible families as well as inform future programming and policies.

Recruitment occurred at an urban primary care clinic located in West Philadelphia serving about 14 000 children annually, of which 75% are publicly insured and approximately 27% are WIC eligible (P.J., T.G., personal communication, 2022). Among clinic patients, 88% of patients identify as African American, 4% as Latino, and 3% as non–English speaking (P.J., T.G., personal communication, 2022). Eligible caregivers were recruited by 2 study team members (P.J. and B.J.V.) via 2 methods. Between December 2019 and February 2020, participants were recruited via telephone from a list of families who initially completed surveys in the clinic waiting room to gauge interest in a mobile WIC office and who consented to future contact. Subsequently, because of pandemic-related changes in office practices, electronic medical records were queried to identify families that received a WIC letter between January 2020 and July 2020, and eligible caregivers were recruited via phone. Participants were assessed for study eligibility at the time of the initial recruitment call. To participate in the study, caregivers had to be >18 years, live in Philadelphia, speak English, and have a WIC-eligible child younger than age 5 years who received care at the previously mentioned clinic. Although all participants were asked about FMNP use, redemption of FMNP benefits was not a requirement for study participation.

A semistructured interview guide was developed from literature review and expert opinion.27  Interview questions were grouped into general categories including family’s current and ideal produce intake, facilitators and barriers to produce access, use of food benefits and local food programs, and perceived characteristics of an ideal program to increase produce access. The interview guide was reviewed and modified through an iterative process after the first 2 interviews were conducted. Interviews were performed via telephone by 2 study team members (P.J. and B.J.V.) between August and December 2020 after verbal consent was obtained; the study team members received training in interview techniques and qualitative analysis from a researcher (D.L.C.) with expertise in qualitative research methods. P.J. is a South Asian American female, native English and Hindi and proficient Spanish speaker, and childless. B.J.V. is a white American female, native English speaker, and childless. Both P.J. and B.J.V. were providers at the previously mentioned clinic. Each interview lasted 30 minutes on average. Participants were provided a $25 gift card as compensation for their time. Demographics including sex, race, ethnicity, insurance coverage, and body mass index were abstracted from the electronic medical record for the WIC-eligible child. Caregivers were asked to identify the total number of children and the number of WIC-eligible children in their household and were screened for FI using the 2-question validated Hunger Vital screening tool.28  All study procedures were deemed exempt from ongoing review by the Children’s Hospital of Philadelphia institutional review board.

Interviews were digitally recorded and deidentified as transcribed verbatim. Transcripts were entered into NVivo 12 Software (QRS International) for organization, coding, and data analysis. The initial coding dictionary was established based on questions in the interview guide. We used content analysis with constant comparison with code interviews inductively and deductively to identify emerging themes.

Two study team members (P.J. and B.J.V.) coded the first 2 transcribed interviews and met to examine interrater reliability, resolve coding disagreements by consensus, and revise code definitions. The revised coding dictionary was then used for the next 3 interviews, after which team members again resolved coding disagreements and finalized code definitions. The remaining 25 interviews were coded separately, with 8 additional interviews double coded at set intervals to ensure that interrater reliability remained stable over time with κ > 0.8 at each assessment. Coded transcript sections were reviewed to uncover emerging subthemes and direct quotations were chosen to exemplify these themes. Interviews were conducted until thematic saturation was reached (Table 1).

TABLE 1

Interview Themes With Representative Quotes From Participating WIC-Eligible Caregivers

TopicThemesIllustrative Quotes [Participant No.]
Facilitators and barriers to intake of fruits and vegetables Major barriers to produce access include limited availability, higher cost, and lack of childcare “When you want good produce sometimes you got to travel a little bit and I don’t think that should be the case.” [9]
“.. it’s either gone or they don’t look too good so you’ve got to drive far out and I’m a person that doesn’t drive on the highway. So the only thing is that you have to drive out farther than what’s in your community.” [21]
“I wish I could buy more. It seems like it’s the same amount of money for less.” [30]
“When you have little kids, it’s hard especially if you’re not driving.” [26]
“I don’t have anybody nearby to watch them for me, so it was hard for me to get to the store.” [28]
“I don’t have that much time. That’s a big problem, the fact that I can only go to one [store]. That might be the one that’s the closest.” [181]
“I’m more so time, I need time. Everything is just so constant moving with me in my life right now.” [2] 
Reliable transportation and federal benefit programs are facilitators to produce access “…It’s a big issue because sometimes SEPTA get broken down and stuff like that. It’s really irritating…” [19]
“It’s very helpful, especially when you’re basically the only provider for your baby. It’s very helpful because it’s like, even though you work, that money still has to go towards other things like bills or clothing, diapers, things like that. SNAP and WIC definitely helps out a lot.”[14]
“I’ve been relying on the food stamps to get fruits and vegetables... I don’t have to worry about them cutting it off...They’re always there every month... It’s been a very, a very big impact. Like, it was like, we needed it. We eat more because we got food stamps.” [15] 
Barriers to use of WIC and the FMNP The transition to electronic benefit transfer in the setting of pandemic-driven WIC office closures has made accessing benefits challenging “One thing I would say, the access to WIC. Now, they switched their whole system. You can’t just get your card reloaded in person. You have to drop it off in a dropbox, wait for them to mail it back. One time I waited 3 weeks for the card to come and I had to go out of my pocket and get the milk. That access has been a little weird now because of COVID.” [11]
“...they’ve been closed and they’ve been canceling appointments. And we haven’t got any emails or any calls or anything about them reopening or anything.” [10] 
Caregivers are aware of the FMNP but are unable to regularly access farmer’s markets “Well, I had gotten it, but I haven’t had a chance to go to the farmer’s market. I know that it’s basically fresher, I should say, foods that they have there. I just have not had a chance to go to it.” [26]
“I use[d] it before, but a lot of times those checks don’t fit, to be honest. I’m just being honest because the same thing with the time, with the time and the location.” [20] 
Family level preferences for programs aimed at increasing produce consumption Caregivers want their children to eat more fruits and vegetables “I feel like she could eat more, but she’s very picky in general. It’s hard to pretty much try to get her to eat a lot more vegetables.” [25]
“I wish they’d do better on the fruit than snacks but I wish it was a little more. Every time they want a snack, I wish they’d grab a fruit instead of a bag of chips.” [21]
“I would like for him to eat more of a variety of fruits and vegetables.” [10] 
An ideal food program would be delivery-based, low or no cost, and provide supplemental resources about produce “It would be like a care package, including a variety of different fruits and vegetables and it would be like delivered to the home to make it more accessible...more easy to obtain.” [26]
“I would try like different things. There would be days that I would offer them normal fruits and vegetables, but I also would have like different things that I would offer like exotic fruits and vegetables. Things that are from like different countries and things that they would like to try, maybe they would maybe be interested in or trying different things to cook with...” [3]
“What I think is really great to have inside of a box is the fresh string beans and the fresh broccoli and introduce some things the kids that like... Introduce some fruits to families that they don’t know about...” [8]
“I think it should completely be covered by WIC or SNAP.” [3]
“I would want to pick it out myself with your family. It could be a learning experience. A lot of kids don’t know the different fruits and vegetables. They don’t know what’s a fruit, what’s a vegetable … Get to know your fruits and vegetables that you’re going to eat.” [22]
“Recipes would probably be good for people so they could broaden their horizons and have other different ways of making foods and stuff. That might be helpful because when I see stuff like that, I actually read it.” [20]
“A list or something like that, or a booklet to show you how to make it and different ways you could put fruits and vegetables and the kids’ who said they won’t know it or have fun food maybe for the kids that try to eat.” [6] 
TopicThemesIllustrative Quotes [Participant No.]
Facilitators and barriers to intake of fruits and vegetables Major barriers to produce access include limited availability, higher cost, and lack of childcare “When you want good produce sometimes you got to travel a little bit and I don’t think that should be the case.” [9]
“.. it’s either gone or they don’t look too good so you’ve got to drive far out and I’m a person that doesn’t drive on the highway. So the only thing is that you have to drive out farther than what’s in your community.” [21]
“I wish I could buy more. It seems like it’s the same amount of money for less.” [30]
“When you have little kids, it’s hard especially if you’re not driving.” [26]
“I don’t have anybody nearby to watch them for me, so it was hard for me to get to the store.” [28]
“I don’t have that much time. That’s a big problem, the fact that I can only go to one [store]. That might be the one that’s the closest.” [181]
“I’m more so time, I need time. Everything is just so constant moving with me in my life right now.” [2] 
Reliable transportation and federal benefit programs are facilitators to produce access “…It’s a big issue because sometimes SEPTA get broken down and stuff like that. It’s really irritating…” [19]
“It’s very helpful, especially when you’re basically the only provider for your baby. It’s very helpful because it’s like, even though you work, that money still has to go towards other things like bills or clothing, diapers, things like that. SNAP and WIC definitely helps out a lot.”[14]
“I’ve been relying on the food stamps to get fruits and vegetables... I don’t have to worry about them cutting it off...They’re always there every month... It’s been a very, a very big impact. Like, it was like, we needed it. We eat more because we got food stamps.” [15] 
Barriers to use of WIC and the FMNP The transition to electronic benefit transfer in the setting of pandemic-driven WIC office closures has made accessing benefits challenging “One thing I would say, the access to WIC. Now, they switched their whole system. You can’t just get your card reloaded in person. You have to drop it off in a dropbox, wait for them to mail it back. One time I waited 3 weeks for the card to come and I had to go out of my pocket and get the milk. That access has been a little weird now because of COVID.” [11]
“...they’ve been closed and they’ve been canceling appointments. And we haven’t got any emails or any calls or anything about them reopening or anything.” [10] 
Caregivers are aware of the FMNP but are unable to regularly access farmer’s markets “Well, I had gotten it, but I haven’t had a chance to go to the farmer’s market. I know that it’s basically fresher, I should say, foods that they have there. I just have not had a chance to go to it.” [26]
“I use[d] it before, but a lot of times those checks don’t fit, to be honest. I’m just being honest because the same thing with the time, with the time and the location.” [20] 
Family level preferences for programs aimed at increasing produce consumption Caregivers want their children to eat more fruits and vegetables “I feel like she could eat more, but she’s very picky in general. It’s hard to pretty much try to get her to eat a lot more vegetables.” [25]
“I wish they’d do better on the fruit than snacks but I wish it was a little more. Every time they want a snack, I wish they’d grab a fruit instead of a bag of chips.” [21]
“I would like for him to eat more of a variety of fruits and vegetables.” [10] 
An ideal food program would be delivery-based, low or no cost, and provide supplemental resources about produce “It would be like a care package, including a variety of different fruits and vegetables and it would be like delivered to the home to make it more accessible...more easy to obtain.” [26]
“I would try like different things. There would be days that I would offer them normal fruits and vegetables, but I also would have like different things that I would offer like exotic fruits and vegetables. Things that are from like different countries and things that they would like to try, maybe they would maybe be interested in or trying different things to cook with...” [3]
“What I think is really great to have inside of a box is the fresh string beans and the fresh broccoli and introduce some things the kids that like... Introduce some fruits to families that they don’t know about...” [8]
“I think it should completely be covered by WIC or SNAP.” [3]
“I would want to pick it out myself with your family. It could be a learning experience. A lot of kids don’t know the different fruits and vegetables. They don’t know what’s a fruit, what’s a vegetable … Get to know your fruits and vegetables that you’re going to eat.” [22]
“Recipes would probably be good for people so they could broaden their horizons and have other different ways of making foods and stuff. That might be helpful because when I see stuff like that, I actually read it.” [20]
“A list or something like that, or a booklet to show you how to make it and different ways you could put fruits and vegetables and the kids’ who said they won’t know it or have fun food maybe for the kids that try to eat.” [6] 

Of the 200 eligible caregivers, 89 were contacted up to 3 times by phone for recruitment on a rolling basis. Of those contacted, 4 (5%) declined to participate, 50 (56%) were unable to be reached, and 5 (6%) phone numbers were disconnected or invalid. Our sample of 30 caregivers was primarily female (n = 29) and had an average of 3 children per household (Table 2). Fifty-seven percent of participants screened positive for FI.

TABLE 2

Sociodemographic Characteristics of Study Participants and Their Primary WIC-Eligible Child

Participants/Caregivers n = 30
Caregiver sex, n (%)  
 Female 29 (97) 
 Male 1 (3) 
Household characteristics  
 Median number of children (IQR) 3 (1–4) 
 Median number of WIC-eligible children (IQR) 1 (1–2) 
 Mean age of children, y (SD) 5.3 (3.6) 
 Mean age of WIC-eligible children, y (SD) 1.8 (1.1) 
Characteristics of WIC-eligible child  
 Sex  
  Female 13 (43) 
  Male 17 (57) 
 Race  
  Black or African American 24 (80) 
  White 1 (3) 
  Asian 1 (3) 
  Other 2 (7) 
  Multiracial 2 (7) 
 Ethnicity  
  Not Hispanic or Latinx 29 (97) 
  Hispanic or Latinx 1 (3) 
 Insurance coverage  
  Public 28 (93) 
  Private 2 (7) 
 Weight for length/BMI percentile, mean (SD) 50.4 (40) 
 Caregiver-reported food insecurity  
  Yes 17 (57) 
  No 11 (37) 
  Not reported 2 (7) 
Participants/Caregivers n = 30
Caregiver sex, n (%)  
 Female 29 (97) 
 Male 1 (3) 
Household characteristics  
 Median number of children (IQR) 3 (1–4) 
 Median number of WIC-eligible children (IQR) 1 (1–2) 
 Mean age of children, y (SD) 5.3 (3.6) 
 Mean age of WIC-eligible children, y (SD) 1.8 (1.1) 
Characteristics of WIC-eligible child  
 Sex  
  Female 13 (43) 
  Male 17 (57) 
 Race  
  Black or African American 24 (80) 
  White 1 (3) 
  Asian 1 (3) 
  Other 2 (7) 
  Multiracial 2 (7) 
 Ethnicity  
  Not Hispanic or Latinx 29 (97) 
  Hispanic or Latinx 1 (3) 
 Insurance coverage  
  Public 28 (93) 
  Private 2 (7) 
 Weight for length/BMI percentile, mean (SD) 50.4 (40) 
 Caregiver-reported food insecurity  
  Yes 17 (57) 
  No 11 (37) 
  Not reported 2 (7) 

BMI, body mass index; IQR, interquartile range; SD, standard deviation.

Major Barriers to Produce Access Include Limited Availability, Higher Cost, and Lack of Childcare

Many caregivers described limited produce options in their neighborhood and shared that available produce is of lower quality than that offered in more affluent areas. Because of this, many reported the need to travel to other neighborhoods to purchase FV. Additionally, time constraints and higher cost of produce relative to other foods in the setting of competing financial priorities were significant factors affecting access for many caregivers. Some expressed that junk food and fast food were more affordable and convenient than fresh produce. One caregiver described, “…the burger is 99 cents. The salad is like $5.49. Which are you going to choose if you’re low income? You’re going to choose the burger for your kids. And then they wonder why kids are so obese. They’re obese because they can’t afford to give them the right FV that they need” [Participant 8].

Difficulty finding childcare was reported as a barrier to being able to go to the store or market by many caregivers. Caregivers also noted that traveling and shopping with young children created challenges to obtaining produce. Many caregivers reported worsening of barriers to produce access during the COVID-19 pandemic given produce shortages, increased food prices, childcare center closures, and decreased income sources.

Reliable Transportation and Federal Benefit Programs are Facilitators to Produce Access

Some caregivers shared that having a car makes it easier to obtain produce because it provides reliable transportation and allows them to travel to stores with their preferred produce. One caregiver reported, “I drive so it’s not like me getting there or getting back was a problem…If I didn’t have transportation, then it would be a different story for me to be able to go get produce” [Participant 2]. Caregivers expressed that enrollment in both WIC and Supplemental Nutrition Assistance Program (SNAP) increased produce access by allowing them to use limited funds toward other essential purchases such as diapers and medical bills. Some caregivers felt that SNAP benefits were overall more helpful than WIC benefits given the amount of funds provided, reliability of the system, and increased options for use of benefits.

The Transition to Electronic Benefit Transfer in the Setting of Pandemic-Driven WIC Office Closures Made Accessing Benefits Challenging

At the time when interviews were conducted (August–December 2020), WIC benefits were available on electronic benefit transfer (EBT) cards but had to be manually reloaded by WIC staff in person or by mail every 3 to 4 months. Many caregivers described challenges with the overall transition to EBT, including fear of misplacing their card, with subsequent loss of benefits while awaiting replacement, as well as unfamiliarity with the process.

Most caregivers commented that WIC office closures during the pandemic created significant barriers to accessing benefits, given difficulty communicating with WIC staff and reliance on postal mail for reloading. One caregiver shared her experience: “I just stopped going…because they want me to drop off the card, come pick up the card…I don’t have the time with the hours that they give me…Then they want to mail it back to me instead of me just being [able] to …load the benefits” [Participant 20].

Caregivers Are Aware of the FMNP but are Unable to Regularly Access Farmer’s Markets

FMNP voucher amounts and eligibility vary by state.22  In Pennsylvania, pregnant, breastfeeding, and postpartum women, and children ages 6 months to 5 years who participate in WIC are eligible to receive $24 (4 checks of $6 each).29,30  Vouchers are provided during WIC appointments in the spring and summer for redemption between June 1 and November 30.29,30  During the COVID-19 pandemic, vouchers were mailed to participants’ homes because of office closures. Most caregivers described that they were aware of FMNP, but it was challenging to access the markets. Caregivers described that the markets were located far from them and required access to a car. Furthermore, parking costs and limited market hours were prohibitive to using them regularly. One caregiver commented, “At least having one in the city instead of so far away where people have to pay more money to get to…and then we got to end up paying for parking. There’s a lot that goes with it” [Participant 29]. Several caregivers described that they would like to use their FMNP benefits to purchase produce in grocery stores rather than at farmer’s markets alone. Finally, some felt that the amount provided by the vouchers was too low.

Caregivers Want Their Children to Eat More FV

Most caregivers expressed a desire for their children to eat more produce, regardless of their children’s current level of FV intake. One caregiver shared, “I don’t want my kids to get stuck on junk food and candy… I want them to be able to have FV in their system” [Participant 19]. Some children were described as “picky”; however, several caregivers reported that they tried to encourage produce consumption through modeling and regularly offering a variety of FV.

An Ideal Food Program Would Be Delivery-Based, Low or No Cost, and Provide Supplemental Resources About Produce

When asked to describe an ideal food program aimed at increasing produce access, most caregivers highlighted the need for a delivery-based program to address barriers to grocery shopping. One caregiver stated, “For a lot of people, delivery would be better. Because sometimes it’s hard for a lot of low-income people to travel…[delivery] would help a lot of families” [Participant 25]. However, some described that it may be better to offer a pickup option to allow for produce self-selection and further engagement for children by learning about different types of FV.

Regarding cost, most participants felt the produce should be free or covered by benefits. However, some did suggest use of a sliding scale or donation system with a small fee of $5 to $20 for those who can afford it. One described, “It all depends on the income and if they don’t get that much, they shouldn’t have to pay that much” [Participant 17].

Caregivers highlighted that offering a wide variety of FV could help expose families to new produce options. There were mixed opinions about who should select the produce. Some participants felt it was fine to receive a preselected mix of produce and others preferred that families pick out the produce because of cultural, taste, and dietary preferences. Most caregivers also highlighted the importance of engaging children with produce through age-appropriate activities and educating caregivers by providing recipes and cooking classes.

Federal food programs, such as WIC, play a key role in improving nutrition among low-income families. However, WIC benefits are significantly underused, and the COVID-19 pandemic created additional barriers in accessing these benefits because of office closures, communication barriers, and mail delays.20,31,32  Our study adds key insights to the literature by exploring experiences with produce access among WIC-eligible families during the COVID-19 pandemic. Additionally, we describe caregiver preferences for food assistance programs that can help inform future programming aimed at increasing WIC use and produce access.

We identified barriers to produce access for WIC-eligible participants, many of which were consistent with earlier literature.3337  Major barriers included limited availability, lack of convenient purchasing options, higher relative cost, difficulty shopping with young children, and time constraints. Because Pennsylvania selected offline EBT benefit reloading, participants also described challenges with the transition to EBT in the setting of the COVID-19 pandemic and inability to reload benefits electronically.3840  Challenges exacerbated by the COVID-19 pandemic included worsened produce shortages, lack of childcare, and decreased access to WIC benefits because of office closures. Consistent with previous literature, owning a vehicle and receiving both SNAP and WIC benefits were described as facilitators to purchasing produce.41 

Participants described that an ideal food program would include an option for delivery, a wide variety of FV, and provision of recipes and produce-oriented children’s activities. Previous studies that piloted online ordering and home delivery demonstrate high acceptability among WIC-eligible participants.39,4244  Additionally, participants suggested that a program would be most helpful if free or covered by benefits. Based on our findings, expansion of delivery-based grocery options that are covered wholly or partially by WIC benefits is an ideal next step in facilitating access to fresh produce and addressing FI among WIC-eligible families.45,46  Delivery-based services are especially needed during emergencies such as the COVID-19 pandemic because they promote social distancing and allow participation by families with young children who face additional barriers to grocery shopping. There is also an opportunity to engage children through education initiatives paired with produce delivery and affect children’s food preferences for FV as they grow into adolescence and adulthood.

A major strength of our study is the focus on obtaining direct, actionable feedback from WIC-eligible caregivers on barriers to use of benefits and how to optimize benefit use to increase produce access. Rather than assuming participant needs and desires, our study allows the voice of the community to drive future intervention and policy change. In addition, this is among the first studies to describe barriers to use of FMNP vouchers during the COVID-19 pandemic. Despite these strengths, our study has several limitations. The generalizability of our findings may be limited as our participants were drawn from English-speaking WIC-eligible caregivers in West Philadelphia. Although rates of WIC participation in Philadelphia (48.4%) were similar to statewide (52.7%) rates in early 2021, most WIC participants in Philadelphia identified as African American (52%), whereas statewide they identified as white (71%).47  Additionally, although WIC is a national program, it is administered at the state level, leading to variation in operations across states.48,49  Our findings may be particularly applicable to states that have selected offline WIC benefit reloading and to other metropolitan areas, which account for 85% of households experiencing FI nationally.40,50  Because of resource limitations, non–English-speaking families were excluded from our study. Given the interview-based nature of our study and potential sensitivity of questions, participant answers may have been affected by social desirability bias, although the interviewers encouraged honesty, refrained from judgment, and took measures to preserve participant anonymity.

Concurrent timing with the WIC EBT transition and the COVID-19 pandemic is both a strength and limitation of our study. This allowed for discovery of key insights that can help optimize the payment transition and address food access during a national emergency. However, participants may have difficulty separating their experiences with WIC during COVID-19 from those before, despite specific prompts on relevant timeframe to consider for each question.

Our study demonstrates a desire for better access to fresh produce among WIC-eligible families and highlights multiple barriers, which have been worsened by the COVID-19 pandemic. Caregivers described a preference for delivery-based, low-cost food programs covered by federal benefits, with inclusion of recipes and children’s activities to increase produce intake among children. Informed by caregiver preferences for food programs identified in this qualitative study, we partnered with local community organizations to create a low-cost produce delivery program. Future study will evaluate the effect of price on participation in a produce delivery program for WIC-eligible families as well as the program’s impact on produce consumption. Future larger scale studies on acceptability, feasibility, and effectiveness of produce delivery options to increase produce access and use of benefits among WIC-eligible families are needed to inform federal food benefit programs and improve long-term health among this population.

We thank all the caregivers who shared their time and voices with us. We also thank the staff at N.O.R.T.H. Inc. of the Philadelphia WIC Program and at the Children’s Hospital of Philadelphia Care Network - Cobbs Creek for their ongoing efforts in serving the children of Philadelphia. We also thank Dr. Cynthia Mollen who provided thoughtful feedback on our manuscript.

Dr Joshi conceptualized and designed the study, drafted the initial manuscript, designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript. Dr Van Remortel conceptualized and designed the study, designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript. Dr Cullen conceptualized and designed the study, supervised the design of the data collection instruments and data analysis, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: This project was supported by the Community Access to Child Health resident grant program through the American Academy of Pediatrics.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

FI

food insecurity

EBT

electronic benefit transfer

FMNP

Farmers’ Market Nutrition Program

FV

fruits and vegetables

SNAP

Supplemental Nutrition Assistance Program

WIC

Special Supplemental Nutrition Program for Women, Infants, and Children

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