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Public Health Nutrition: page 1 of 8 doi:10.1017/S1368980008004308
Perceived access to fruits and vegetables associated with
increased consumption
Erin M Caldwell*, M Miller Kobayashi, WM DuBow and SM Wytinck
National Research Center, Inc., 3005 30th Street, Boulder, CO 80303, USA
Submitted 8 April 2008: Accepted 28 October 2008
Abstract
Objective: To examine the association between fruit and vegetable access in the
community and change in fruit and vegetable consumption among participants in
community-based health promotion programmes.
Design: Fruit and vegetable consumption and perceived access to fresh fruit and
vegetables were measured by self-administered questionnaires at programme
start, end and 1-year follow-up. Community produce availability was determined
by grocery store assessments measuring the display space devoted to fruit
and vegetable offerings, as well as price, variety and freshness. A total of nine
communities were studied; 130 participants completed the fruit and vegetable
portions of the questionnaires and could be linked to grocery store assessments.
Results: Participants made modest but significant increases in fruit and vegetable
consumption from programme start to end: the average increase was 2?88 (95 %
CI 1?52, 4?25) servings weekly; the average increase from start to follow-up was
2?52 (95 % CI 1?09, 3?95) servings weekly. Greater perceived access to fruits and
vegetables was significantly associated with higher increases in fruit and vege-
table consumption from programme start to programme end. Greater availability
of produce was associated with greater increases in fruit and vegetable servings
from programme start to programme end as measured by store assessments.
Conclusions: Environmental factors, such as access to fruits and vegetables, can
modify the effects of community interventions. Interventions with the goal of
increasing fruit and vegetable consumption should consider focusing on increasing
access to fresh fruits and vegetables in target communities. Similarly, researchers
may want to study access as an intervention, not just a contextual variable.
Keywords
Environment
Access
Fruits
Vegetables
Community-based programme
It is a widely accepted opinion that Americans eat too few
fruits and vegetables and that this nutrition deficit con-
tributes to the prevalence of overweight and obesity
(1–3)
.
Many interventions in recent years have been aimed at
increasing the consumption of fruits and vegetables. In the
USA, the government has intervened with a public health
campaign, Healthy People 2010, intended to improve
nutrition and increase physical activity among its residents.
The national Healthy People 2010 objectives for fruit
and vegetable consumption are to:
1. Increase the proportion of persons age 2 years and
older who consume at least 2 servings of fruit daily
(US target 75 %).
2. Increase the proportion of persons aged 2 years and
older who consume at least 3 servings of vegetables
daily, with at least one-third being dark green or deep
yellow vegetables (US target 50 %)
(4,5)
.
Additionally, it is the recommendation of the National
Cancer Institute that Americans eat 5 or more fruits and
vegetables each day for better health
(6)
.
Despite government-sponsored public information
outreach and consequent increased awareness among
Americans, most still do not eat the recommended
amounts of fruits and vegetables
(7)
.
Of the various reasons proposed to explain the US
nutrition deficit, one important reason is access to pro-
duce within the communities in which people live. Many
researchers hypothesize that the presence of healthy food
choices in the environment may influence eating beha-
viours positively
(8–15)
. The vast majority of research that
has focused on youths’ access to fruits and vegetables has
found that access, whether at home or at school, does
increase children’s healthier food choices
(16)
. One study
even found this to be true when no educational or home
component was involved
(11)
.
Although it is widely accepted that the environment
can play a large role in enhancing or detracting from
individuals’ healthy choices, few studies have examined
the relationship between community access to fruits and
vegetables, through supermarkets, local grocers and farm-
ers’ markets, and levels of fruit and vegetable consumption.
SPublic Health Nutrition
*Corresponding author: Email erin@n-r-c.com rThe Authors 2008
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Most nutrition studies focusing on environment have
been confined to the school and home environments.
However, in a separate but related field, physical activity
research has taken into account broader environmental
correlates, such as walking paths, the built environment,
lighting and other potential contributors to healthful
activities
(17–25)
.
The purpose of the present evaluation was to examine
whether adult and youth participants in community-
based programmes made and sustained healthy lifestyle
changes around nutrition and physical activity. This study
is unique in that it examines the effect of fruit and
vegetable access as it fosters or amplifies the effect of
other diet-related interventions.
The present study examined participant survey results
from community-based programmes supported by The
Colorado Trust’s Colorado Healthy People 2010 Obesity
Prevention Initiative. Although other programmes were
part of this initiative, the programme participant data used
in the current analysis came from only those programmes
reporting moderate to high programmatic emphasis on
fruit and vegetable consumption. The analyses presented
herein explore the change in individual intake of fruits
and vegetables. They also demonstrate the association
between individual intake and access to fruits and vege-
tables in the communities in which the programmes were
implemented.
Methods
Intervention
The Colorado Trust, a grant-making foundation, estab-
lished the Colorado Healthy People 2010 Initiative (the
Initiative) to ‘help Coloradans learn about and take steps
to lead healthier, longer lives, and to decrease health
disparities among different populations’
(26)
. The 4-year
Initiative was designed to aid Coloradans in achieving
Healthy People 2010 objectives while also paying atten-
tion to local priorities. The state was divided into five
regions; each with a different focus. In two of the regions,
community-based programmes were designed and funded
with a focus on increasing physical activity (north-western
Colorado) and preventing diabetes (south-eastern Color-
ado). None of the interventions included in the present
study aimed at altering access to fruits and vegetables in
their communities.
Because all of the interventions were community-
inspired and community-based, they varied in content,
duration and intensity. Some programmes sought to
educate individuals about making healthy nutritional
choices while grocery shopping, teaching label reading
and interpretation, while others provided cooking classes
or encouraged local restaurants to mark healthier meal
options on menus. Most programmes lasted from 4 to 16
weeks, although some enrolled participants for the length
of the grant. Target populations varied as well and included
employees, older adults, high-risk individuals and general
community members, both adults and youths.
Surveying participants
Self-administered questionnaires were completed by
participants when they started a programme, finished a
programme and one year after programme end. The
questionnaire comprised several question sets designed
to measure the outcomes of participant interest as well as
participant characteristics that were hypothesized to
influence behaviour change.
Participant confidentiality was protected through a
replicable process wherein each individual constructed
their own unique identifier (ID) and recorded it on their
survey. All participants over 18 years of age completed a
consent form, and those under 18 had a parent or guar-
dian complete the form. Respondent contact information
was entered into a database to allow survey tracking, but
could not be linked to survey responses. The entire
evaluation was approved by an external institutional
review board (IRB), the Western Institutional Review
Board. As necessary, inter-IRB agreements were reached
at those sites that had their own IRB.
Programme staff gave eligible participants the pro-
gramme start surveys. In some cases, they collected them
after completion and submitted them to the evaluator. In
other cases, they gave participants a postage-paid envel-
ope in which to send their completed survey directly to
the evaluator. At programme end, for some programmes
staff administered the survey to their participants; for
others, the evaluator mailed a survey directly to partici-
pants at the appropriate time interval. For follow-up, the
evaluator mailed a programme follow-up survey one year
after programme completion to all participants who had
completed a programme end survey. Respondents were
given incentives for their participation. These varied
depending on the programme, but in most cases were
the equivalent of $US 10 at programme start, $US 10 at
programme end and $US 25 at follow-up.
Over the course of the Initiative, about 8550 partici-
pants were served by the programmes that had a mod-
erate or high emphasis on increasing fruit and vege-
table consumption. The evaluation began in the second
year of the Initiative. For a few programmes that served a
large number of participants, a sampling strategy was
employed in which only groups enrolled in certain
months were invited to participate in the evaluation.
Thus, about 1850 participants were eligible to complete a
survey at programme start. Of those, 1075 completed a
consent form and a survey at programme start. Of those,
684 also completed a programme end survey, while 380
also completed a follow-up survey. Not all surveys were
able to be linked from programme start, end and follow-
up because respondents did not always put their ID on
the surveys, or did not use the same ID on each survey
SPublic Health Nutrition
2 EM Caldwell et al.
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(although the instructions were identical at all time peri-
ods). A total of 290 surveys could be linked from start to
end to follow-up, with 266 actually having completed the
fruit and vegetable consumption questions on their sur-
veys at all three time periods (24?7 % of those who did a
programme start survey). Of these participants (for whom
outcome results are reported), there were 130 participants
who lived in communities where fruit and vegetable
access was measured (for whom the association between
access and behaviour change is reported).
Measures
The question set from the Youth Risk Behavior Survey
(27)
was chosen to assess fruit and vegetable consumption in
the surveys for both adults and youths. Respondents were
asked how often they had consumed various fruit and
vegetable products in the last 7 d. The categories from
which they could choose a response were assigned a
number of servings per week, as shown below:
I did not [consume any] during the past 7 d 0 servings
1 to 3 times during the past 7 d 2 servings
4 to 6 times during the past 7 d 5 servings
1 time per day during the past 7 d 7 servings
2 times per day during the past 7 d 14 servings
3 times per day during the past 7 d 21 servings
4 or more times per day during the past 7 d 28 servings
To calculate the approximate number of fruits and
vegetables consumed per week, the answers to the follow-
ing questions were summed:
1. The number of 100 % fruit juices consumed in the
last 7 d.
2. The number of fruits consumed in the last 7 d.
3. The number of potatoes consumed in the last 7 d.
4. The number of times green salads were consumed in
the last 7 d.
5. The number of times carrots were consumed in the
last 7 d.
6. The number of times other vegetables were consumed
in the last 7 d.
Perceived access to fresh fruits and vegetables was
measured by a question included on the follow-up sur-
vey, ‘How easy or difficult is it for you to get fresh pro-
duce (fruits and vegetables)?’, with the following
response scale: 1 5very difficult, 2 5somewhat difficult,
35somewhat easy, 4 5very easy.
Although a variety of existing grocery store assessments
were examined, none measured directly the availability of
fruits and vegetables, so an assessment was created by the
evaluators. This assessment measured the amount of dis-
play space devoted to produce (including fresh, packaged,
frozen and canned produce, and frozen, canned and
bottled juice), the total varieties of produce available, and
the price of the produce. Display space devoted to fresh
produce was measured by the depth and width of the
various display spaces, while display space devoted to
other types of produce (frozen, canned, etc.) was measured
in a linear fashion, to reflect the typical display set-ups in
Colorado grocery stores. The total types of fresh fruits and
vegetables was counted; for example, if there were five
kinds of apples (e.g. Granny Smith, Gala, Fuji, Braeburn
and Red Delicious), each was counted as a separate variety.
Evaluators made a subjective assessment of the general
freshness of the produce on display, i.e. ‘the proportion of
produce that was fresh (not over-ripe or wilted)’ using the
following scale: all fresh, nearly all fresh, most fresh, some
fresh, most not fresh. Finally, two types of price assessment
were made. A ‘produce basket’ consisting of 1 lb of apples,
1 lb of potatoes, a 64-oz carton of orange juice, a 12-oz can
of apple sauce, a 14-oz can of green beans and a 20-oz
package of frozen corn was priced, using the minimum
price for each. A minimum price for fresh produce was
calculated as the lowest price per 16 oz of any type of fresh
fruits or vegetables available.
This assessment was performed in twenty-four commu-
nities in north-western and south-eastern Colorado. In
communities where there was only one grocery store or
market, the assessment was conducted at that site. In com-
munities with more than one supermarket, the assessment
was conducted in two randomly selected markets. If the
community had a natural food grocery store or specialty
market (such as Whole Foods or Wild Oats), one of the
assessments was conducted at this type of market.
A programme’s emphasis on the outcome, fruit and
vegetable consumption, was partially derived from the
evaluators’ assessments of the programmes’ final reports
to the funder. These assessments were all validated by
the programmes’ technical assistance (TA) providers who
had been designated to them throughout the initiative.
TA providers assigned levels of low, medium and high
outcome emphasis on fruit and vegetable consumption to
each of their designated programmes.
Data analysis
Data were analysed using the SPSS
R
statistical software
package (SPSS Inc., Chicago, IL, USA). Descriptive sta-
tistics, including frequencies, means and standard errors,
were run on the variables used in the analyses.
Dependent ttests were used to test changes in fruit
and vegetable consumption from programme start to pro-
gramme end or from programme start to 1-year follow-up.
Associations of changes in fruit and vegetable con-
sumption with the perceived access to fresh produce
and the grocery store assessment factors were tested by
linear mixed modelling which adjusted for nesting of
participants within programmes or communities. Fruit
and vegetable consumption at programme start was
included as an adjustment factor in all the models. In
addition, the models included whether or not the parti-
cipant was an adult or youth and the respondent’s gender.
SPublic Health Nutrition
Access to produce may increase consumption 3
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Results
As shown in Table 1, programme participants were pri-
marily White, Anglo females. Nearly 80 % of respondents
were female, while 93 % were White and 92 % were non-
Hispanic. The age of participants varied widely; 8 % were
youths under 18 years of age, over a quarter (27 %) were
aged 18–34 years, while 12 % were 65 years of age or older.
It is the recommendation of the National Cancer Insti-
tute that Americans eat 5 or more fruits and vegetables
each day for better health
(6)
. As Table 2 shows, only 11 %
of participants were consuming a total of 35 or more fruits
and vegetables weekly (the equivalent of 5 fruits or
vegetables daily) at programme start; by programme end,
18 % were doing so, and by follow-up, 15 % of evaluation
participants were consuming 35 or more weekly fruit and
vegetable servings. The average number of fruits and
vegetables consumed per week by evaluation participants
at programme start was 18?51, or an average of 2?64 per
day. The average number of fruits and vegetables eaten
per week by programme end was 21?39, an average of
3?06 per day, a statistically significant increase of 2?88
(95 % CI 1?52, 4?25) servings per week. At follow-up, the
average number of fruit and vegetable servings per week
was 21?03, still statistically significantly higher by 2?52
(95 % CI 1?09, 3?95) servings per week compared with
programme start.
As shown in Table 3, a majority of evaluation partici-
pants (55 %) felt it was ‘very easy’ to obtain fresh fruits
and vegetables; 13 % reported it was ‘somewhat’ or ‘very
difficult’ to do so.
Greater perceived access to fruits and vegetables was
significantly associated with higher increases in fruit and
SPublic Health Nutrition
Table 1 Participant characteristics (n266)
n
Percentage who
answered
Percentage of
total
Age (years)
,18 20 7?67?5
18–24 16 6?16?0
25–34 54 20?620?3
35–44 36 13?713?5
45–54 56 21?421?1
55–64 48 18?318?0
65132 12?212?0
Not answered 4 1?5
Gender
Female 206 79?577?4
Male 53 20?519?9
Not answered 7 2?6
Ethnicity
Not Hispanic 223 91?883?8
Hispanic 20 8?27?5
Not answered 23 8?6
Race
White 212 92?679?7
Not White 17 7?46?4
Not answered 37 13?9
Table 2 Participants’ fruit and vegetable consumption (n266)
n% Mean 95 % CI P*SE
Weekly fruit and vegetable servings at start 18?51 17?08, 19?94 0?73
Less than 35 238 89?5
35 or more 28 10?5
Weekly fruit and vegetable servings at end 21?39 19?81, 22?98 0?81
Less than 35 218 82?0
35 or more 48 18?0
Weekly fruit and vegetable servings at follow-up 21?03 19?46, 22?61 0?80
Less than 35 226 85?0
35 or more 40 15?0
Change in fruit and vegetable servings from start to end 2?88 1?52, 4?25 0?0228 0?69
0 or less 114 42?9
1–6 65 24?4
7 or more 87 32?7
Change in fruit and vegetable servings from start to follow-up 2?52 1?09, 3?95 0?0103 0?73
0 or less 128 48?1
1–6 64 24?1
7 or more 74 27?8
*Change from start to end and from end to follow-up tested with two-sided independent ttests.
Table 3 Perceived ease of obtaining fruits and vegetables (n266)
How easy or difficult is it for you to get
fresh produce (fruits and vegetables) n
Percentage who
answered
Percentage
of total Mean SE
260 3?39 0?05
Very difficult 8 3?13?0
Somewhat difficult 26 10?09?8
Somewhat easy 83 31?931?2
Very easy 143 55?053?8
Not answered 6 2?3
4 EM Caldwell et al.
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vegetable consumption from programme start to pro-
gramme end (P50?011, see Table 4). The association
neared statistical significance for increases from pro-
gramme start to follow-up (P50?079).
Grocery store assessments measured several aspects
of the community availability of fruits and vegetables.
Table 5 shows the descriptive statistics for the factors
measured using the community as the unit of analysis.
The average total square metres of display space devoted
to fresh fruits and vegetables was 132 m
2
. The average
minimum price of a ‘basket of produce’ was $US 12?43.
As shown in Table 6, for almost all of the factors
measured, increased availability of produce was asso-
ciated with greater increases in fruit and vegetable
servings from programme start to programme end.
Participants in communities with grocery stores with
greater display space devoted to fresh fruits and vege-
tables had greater increases, on average, in fruit and
vegetable consumption from programme start to pro-
gramme end. Likewise, participants in communities with
grocery stores that had more varieties of produce had
greater average increases in weekly servings of fruits and
vegetables. Participants who lived in communities in
which there was more than one grocery store increased
their fruit and vegetable consumption by 7?27 (2?90,
11?64) servings per week more from programme start to
end, on average, than participants in communities in
which there was only one grocery store. Those who lived
in communities where organic produce was available
made greater increases, on average, in fruit and vegetable
consumption from programme start to end than did those
who lived in communities where no organic produce was
available. None of these factors was associated with
increases in fruit and vegetable consumption from pro-
gramme start to follow-up.
The average price of produce was associated with
increases in fruit and vegetable consumption; the greater
the price of the produce, the greater the increase, on
average, in fruit and vegetable consumption, from
programme start to end, and from programme start to
follow-up.
Discussion
The present study showed across the age span of pro-
gramme participants that the vast majority of these
predominantly White, Anglo females began their healthy
lifestyle programmes eating well below the recom-
mended weekly average of fruits and vegetables. Only
about one in ten were eating an average of 5 fruits and
vegetables daily at programme start. The programmes
included in the present study aimed at increasing indivi-
dual participants’ consumption of fruits and vegetables.
By programme end, about two in ten were eating the
recommended amounts of fruits and vegetables. The
change programme participants made in their fruit and
vegetable consumption, albeit small, was statistically
significant. Although the proportion of people meeting
the dietary standards dropped off to 15 % at the 1-year
SPublic Health Nutrition
Table 4 Association of perceived access to fresh produce with change in fruit and vegetable consumption (n260)
Association with change from start to end Association with change from start to follow-up
b95 % CI SE P*b95 % CI SE P*
Perceived access to fruits and
vegetables-
2?08 0?50, 3?66 0?79 0?011 1?53 20?18, 3?23 0?87 0?079
*Linear mixed modelling, adjusted for nesting of participants within programmes, target population (youths or adults), sex and fruit and vegetable consumption
at programme start.
-15very difficult, 2 5somewhat difficult, 3 5somewhat easy, 4 5very easy.
Table 5 Grocery store characteristics
Communities assessed (n9)
Characteristic Mean SE
Total square metres of fresh fruit and vegetables 132 41
Total linear metres of frozen, canned, bottled, cartons of fruits, vegetables and juices 10 2
Total number of varieties of fresh fruit and vegetables 119 22
Number of stores in community* 0?67 0?17
Freshness of produce-0?86 0?07
Availability of organic produce-
-
0?56 0?24
Minimum price of produce baskety12?43 0?39
Minimum price of fresh produceJ0?80 0?06
*0 5one store ; 1 5more than one store.
-0?00 5some; 0?50 5most; 0?75 5nearly all; 1?00 5all; a scale point of ‘most not fresh’ was never used.
-
-
05in no stores; 1 5in one store; 2 5in two stores.
yIn $US; basket comprises 1 lb of apples, 1lb of potatoes, a 64-oz carton of orange juice, a 12-oz can of apple sauce, a 14-oz can of green
beans and a 20-oz package of frozen corn.
JIn $US; lowest price per 16 oz – any type.
Access to produce may increase consumption 5
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follow-up, the change in the number of servings from
start to follow-up also was statistically significant.
Studies of single-programme interventions also have
found sustained increases in fruit and vegetable con-
sumption. Two studies focusing on school-based inter-
ventions found sustained increases at a 4-month follow-
up
(28)
and a 2-year follow-up
(29)
, while one study in a
community clinic serving low-income women showed
sustained change at a 12-month follow-up
(30)
. All three
concluded that multi-component interventions showed
greater promise for sustaining individual behavioural
change. A study of callers to a Cancer Information Service
found, in both the pilot and replication, that educational
outreach showed a sustained increase in fruit and vege-
table consumption at 4-month follow-up
(31,32)
.
In general, behaviour change is difficult to effect,
whether because of a lack of individual motivation,
counterproductive environmental and social influences,
or a lack of follow-through
(33–37)
. Because of the chal-
lenges inherent in improving individual nutrition, public
health advocates may be interested in the fact that parti-
cipants were able to not only increase their intake of fruits
and vegetables but sustain the increase for at least a year
following their participation in a programme. Because the
programmes in the present study were wide-ranging in
terms of methodology, duration and frequency, they
do not lend themselves to a programmatic prescription.
But because the study also included data on perceived
environment as well as community factors, more can be
known about what may help and hinder this type of
individual behaviour change.
Little attention has been given to the perceived envir-
onment in nutrition studies. Instead, studies of environ-
mental correlates have looked at the influence on
consumption of having different types of foods (healthful
and unhealthful) in the immediate environment, such as
the school, home or workplace
(38)
. The present study
included a survey question specifically asking programme
participants how easy or difficult access to fruits and
vegetables was for them. Greater perceived access was
associated with higher increases in fruit and vegetable
consumption at both programme end and follow-up,
although significantly so only at programme end.
In addition, each of the communities was assessed by
the researchers for the quality and quantity of fruit and
vegetable access. Many environmental factors in the
community were shown to be influential. The number
and size of the fruit and vegetable offerings was asso-
ciated with increased intake. In addition, the quality
or attractiveness of the produce itself was associated
with increased intake, as measured by variety, the
preponderance of fresh produce among the non-canned
varieties, and the presence of organic produce. Price was
also assessed, as previous research has shown it to be a
contributing factor in individual food choices
(12,39,40)
.
Contrary to the authors’ hypothesis that less expensive
SPublic Health Nutrition
Table 6 Association of grocery store assessments with change in fruit and vegetable consumption (n130)
Association with change from start to end Association with change from start to follow-up
Produce assessment b95 % CI SE P*b95 % CI SE P*
Total square metres of fresh fruit and vegetables 0?02 0?00, 0?04 0?01 0?0137 0?01 0?00, 0?03 0?01 0?1635
Total linear metres of frozen, canned, bottled, cartons of fruits,
vegetables and juices
0?46 0?12, 0?80 0?17 0?0092 0?12 20?22, 0?46 0?17 0?4696
Total number of varieties of fresh fruit and vegetables 0?04 0?01, 0?07 0?01 0?007 0?02 20?01, 0?05 0?01 0?1533
Number of stores in community-7?27 2?90, 11?64 2?21 0?0013 3?69 20?65, 8?03 2?19 0?0947
Freshness of produce-
-
9?01 0?20, 17?81 4?45 0?045 5?18 23?38, 13?74 4?33 0?2337
Availability of organic producey4?57 0?76, 8?38 1?92 0?0191 2?71 21?01, 6?42 1?88 0?152
Minimum price of produce basketJ3?61 1?32, 5?89 1?15 0?0022 1?67 20?59, 3?93 1?14 0?1467
Minimum price of fresh producez16?61 2?82, 30?41 6?97 0?0187 14?54 1?21, 27?87 6?74 0?0328
*Linear mixed modelling, adjusted for nesting of participants within programmes, target population (youths or adults), sex and fruit and vegetable consumption at programme start.
-05one store; 1 5more than one store.
-
-
0?00 5some; 0?50 5most; 0?75 5nearly all; 1?00 5all; a scale point of ‘most not fresh’ was never used.
y05in no stores; 1 5in one store; 2 5in two stores.
JBasket comprises 1 lb of apples, 1 lb of potatoes, a 64-oz carton of orange juice, a 12-oz can of apple sauce, a 14-oz can of green beans and a 20-oz package of frozen corn.
zLowest price per 16 oz – any type.
6 EM Caldwell et al.
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produce would be associated with increased consump-
tion, the study found that, in fact, increased cost was
associated with increases in participants’ fruit and vege-
table consumption. This could be explained by the fact
that higher prices in Colorado are often found in those
grocery stores that offer more variety, more organic
produce and higher-end healthful food items. A more
produce-rich state might show different associations
between variety and cost. Additionally, higher prices and
greater variety may be indicators of more affluent com-
munities, so individual access might be greater for those
who can afford fruits and vegetables, as opposed to often
less-expensive, energy-dense, processed foods.
Although none of the programmes aimed at changing the
availability of produce in the community, they did seek to
change their participants’ predilection toward choosing
fruits and vegetables from among all available options.
Thus, availability may have been important in the indivi-
dual’s capacity to alter eating behaviours. The study’s find-
ings suggest that there is an association between access to
produce and greater changes in individual consumption.
The strengths of the present study include the size and
type of sample; results are drawn from a wide range of
programmes that incorporated programming aimed at
increasing fruit and vegetable consumption. The ‘commu-
nity-based setting’ for each of the programmes included in
the evaluation may lead to more generalizable results that
have real-world applications. In addition, a relatively long
follow-up period was examined by asking for fruit and
vegetable consumption one year after programme end.
Limitations include the cross-sectional, multi-purpose
nature of the study. An experimental design was not
employed; rather, participants in funded interventions were
enrolled. The funded programmes that included a fruit and
vegetable component in their programming varied in terms
of target population, intervention duration, frequency of
contact and type of contact. An unidentified portion of the
sample was self-selected, meaning there is some selection
bias in the results not accounted for in the measures.
Conclusions and applications
Participants increased their fruit and vegetable consumption
at programme end and at the 1-year programme follow-up.
There was a correlation between participant outcomes and
community factors. Increase in individual fruit and vege-
table consumption was positively correlated with commu-
nities that had ready access to fresh fruits and vegetables.
Environmental factors, such as access to fruits and vege-
tables, can modify the effects of community interventions. It
may be useful for interventions with the goal of increasing
fruit and vegetable consumption to focus on increasing
access to fresh fruits and vegetables in the target commu-
nities. Similarly, researchers may want to study access as an
intervention, not just a contextual variable.
Acknowledgements
This evaluation was funded by The Colorado Trust. The
authors declare that there was no conflict of interest. E.M.C.
managed the entire project, helped to create the study
design, helped design the participant-level questionnaires,
conducted all data analysis, and wrote the methods and
results sections of the present manuscript. M.M.K. helped to
create the study design, helped design the participant-level
questionnaires, consulted on data analysis and reviewed the
manuscript. W.M.D. wrote the introduction, discussion and
conclusion sections, and participated in data collection,
primarily qualitative and grocery store assessments. S.M.W.
created the grocery store assessment instrument and index,
collected the grocery store assessment data, and reviewed
the methods section of the manuscript.
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