Understanding the Adoption and Implementation of Fruit and Vegetable Voucher Incentives In High-Obesity Rural Communities: A Qualitative Study from Missouri

Background/Purpose: Missouri continues to fall below the national average for many health behaviors and outcomes, including obesity. While research tends to focus on individual-level outcomes such as dietary intake, there is very limited research on community-level strategies such as fruit and vegetable voucher incentives (FVVIs). The study helps to fill this gap by exploring facilitators and barriers to the adoption and implementation of FVVIs in rural Missouri counties with adult obesity rates exceeding 40%.

Methods: Thirty-two in-depth, semi-structured interviews were conducted with professionals knowledgeable about FVV residing in 10 rural counties in South Central and Southeast Missouri as part of the CDC-funded Missouri High Obesity Program (HOP). Participants were recruited using purposive sampling to obtain insight from community members who self-identified as professionals in food systems governance and nutrition programs. Recruitment was conducted through flyers distributed via local University of BLINDED Extension offices. The sample comprises 50% female and 78% Black/African American participants, with 60% aged 25-34 years old. Guided by the principles of grounded theory, we employed open-ended questions to explore their perspectives on facilitators and barriers to the adoption and implementation of FVVIs. Interviews were conducted via Zoom at times convenient for participants and each interview did not exceed 60 minutes. All interviews were transcribed with verbatim and deidentified copies were stored separately from participants’ demographic data. Thematic analysis was conducted using NVivo 15 for systematic data management and coding. Each transcript was randomly assigned to two of three coders, and coding dyads engaged in iterative debriefing sessions to assess inter-coder reliability.

Results: Thematic analysis shows that professionals have shared three unique, yet intertwined perspectives regarding facilitators and barriers to the adoption and implementation of FVVIs: those of community residents, agricultural producers, and professionals. For facilitators, community residents’ perspectives primarily centered on factors associated with healthy eating (increased FV consumption), including greater awareness of FVV programs, improved access to healthy food, and the availability of culturally relevant and affordable healthy food options. In contrast, producers’ perspectives emphasized factors associated with increased production of healthy foods, including improved availability of fresh food, improved storage handling of fresh food, producer training, and enhanced technology. Finally, professionals’ perspectives focused on factors related to the promotion and implementation of FVV programs, including increased availability and access to FVV programs, engagement with trusted community members/leaders, culturally sensitive program design, enhanced technology and application systems, improved digital literacy, and use of social media and advertisements. Across all perspectives, common barriers included cultural complexity, language challenges, stigma, mistrust, transportation limitations, and limited availability of fresh food options.

Conclusions/Implications: High obesity rates and related chronic conditions lead to prolonged effects particularly on rural community health. Our findings highlight the importance of considering multi-level, stakeholder-informed approaches that integrate the diverse perspectives from professionals to enhance the effectiveness of FVV programs. Promoting these facilitators and addressing the barriers to the adoption and implementation of FVV programs are critical for reducing high obesity rates, fostering sustainable and healthier communities, and ultimately reducing health disparities in rural Missouri.