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Address correspondence to: Darcy A. Freedman, PhD, Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University, 11000 Cedar Ave, Cleveland, OH 44106.
Recent evidence indicates a widening gap in fruit and vegetable (F/V) consumption between high- and low-income Americans. This gap is related, in part, to decreased access to food retailers that sell fresh F/V in low-income communities. Farmers’ markets are identified as a strategy for improving F/V consumption by increasing access to these foods.
Objectives
The aim of this systematic review was to examine literature published from 1994 to 2014 to identify facilitators and barriers of farmers’ markets use, particularly among low-income consumers.
Design
Peer-reviewed literature was identified in Ebsco Host (Academic Search Complete). Inclusion criteria for abstract review was primary research focused on farmers’ market use identifying 87 studies for full-text review. Full-text review identified articles focused on facilitators and/or barriers of farmers’ market use resulting in 49 articles. At least two reviewers completed review of all articles.
Results
Of the 49 articles, 39% specified inclusion of low-income consumers and fewer than 15% focused on racial and ethnic minorities. Few studies were guided by theory and/or used standardized metrics. Results indicate farmers’ market use is influenced by multiple economic, service delivery, spatial-temporal, social, and personal factors. Among studies that included low-income populations (n=19), key barriers to farmers’ market use were perceptions that food assistance benefits were not accepted, belief that food variety at farmers’ markets was limited, lack of access to transportation, lack of racial/ethnic diversity in the market space, and mismatch between markets and personal lifestyles. There is wide variation in study design and reporting standards and infrequent use of standardized measures limiting comparisons across studies.
Conclusions
There is a need to establish valid and reliable metrics and reporting standards for evaluating farmers’ markets. Findings may inform interventions, programs, and policies to promote farmers’ market use.
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During the past 2 decades, the number of farmers’ markets in the United States has grown dramatically from 1,755 in 1994 to 8,268 in 2014.
Prior research has illuminated the variety of farmers’ market models in existence, which range from farm stands with as few as one farmer selling produce to multivendor farmers’ markets selling food for wholesale.
Regardless of the model, farmers’ markets represent an alternative compared with conventional food retail by offering an opportunity for consumers and producers to directly interact in food procurement transactions that focus on accessing farm-produced products such as fresh fruits and vegetables (F/V).
From a public health perspective, farmers’ markets have been identified as a recommended environment-related intervention approach for two reasons. First, there is evidence that farmers’ market use is associated with improved F/V consumption
Effect of a targeted subsidy on intake of fruits and vegetables among low-income women in the Special Supplemental Nutrition Program for Women, Infants, and Children.
A diet high in fatty fish, bilberries and whole-grain products improves markers of endothelial function and inflammation in individuals with impaired glucose metabolism in a randomised controlled trial: The Sysdimet study.
A second reason driving public health interest in farmers’ markets is related to increased awareness of structural barriers to accessing F/V, particularly in low-income communities.
Farmers’ markets are emerging in these so-called food deserts as an immediate response to improve spatial access to healthy foods because the development of conventional food retailers such as supermarkets and grocers requires substantial investments that may not be realized in the short term.
Farmers’ markets as keystones in rebuilding local and regional food systems.
in: Hinrichs C.C. Lyson T.A. Remaking the North American Food System: Strategies for Sustainability. University of Nebraska Press,
Lincoln, NE2007: 65-83
Farmers’ markets have the potential to foster healthy diet by improving access to nutritious foods.
The purpose of our work was to conduct a systematic review of published literature to examine the following research question: Among low-income populations, compared with middle- and high-income populations, what are the barriers and facilitators of farmers’ market use? This question was guided by evidence suggesting low-income individuals are disproportionately affected by food access barriers that result in increasingly disparate diet quality.
Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: Systematic review and dose-response meta-analysis of prospective cohort studies.
Thus, low-income populations have the potential to achieve greater benefits from farmers’ markets.
Methods
The systematic review protocol was developed by the lead author in consultation with a library sciences expert and with feedback from five coauthors. The protocol involved three distinct stages. First, peer-reviewed articles published in full text between 1994 and 2014 were identified using Ebsco Host (Academic Search Complete) with the search term farmers market* as the subject. This was conducted in September 2014 and again in January 2015. This resulted in identification of 954 articles with 282 remaining after duplicates were removed.
Second, 282 abstracts were screened by two reviewers. Inclusion criteria for abstract screening included available in English; focused on the United States and other high-income countries
; contained primary analysis of qualitative or quantitative data; and addressed reasons for using farmers’ markets, farmers’ market characteristics, or barriers or facilitators to farmers’ market use. Discrepancies between reviewers were discussed by a six-member research team and decided upon collectively. Abstract screening resulted in identification of 87 articles for full-text review.
Third, eligibility review involved evaluation of all 87 articles by two reviewers following an iterative training process to ensure review procedures were systematic. Inclusion criteria for full-text review included that the article met initial screening inclusion criteria from stage two and focused on barriers and/or facilitators of farmers’ market use. This resulted in removal of 38 articles. For all included articles (n=49), information about the study aims and approach, study population demographic characteristics, and factors related to use of farmers’ markets were extracted and compared for accuracy. Given the diversity of research approaches and reporting standards among studies included in this review, systematic assessment of bias within each individual study was examined by highlighting variability in reporting trends related to study details that influence selection and sampling bias (see Table 1). Factors related to farmers’ market use were categorized based on an existing framework of nutritious food access that includes five domains: economic (ie, cost and prices,), spatial-temporal (ie, location and transportation), service delivery (ie, food quality/variety and customer service), social (ie, social interaction and cultural foodways), and personal factors (ie, personal behaviors or attitudes).
This involved systematic coding of all articles to identify barriers and facilitators of farmers’ market use related to each of the five domains of nutritious food access. An “other” category was established for use during the evaluation of articles; however, all barriers and facilitators identified in the literature fit into one of the five domains of nutritious food access. Discrepancies between reviewers were discussed by a three-member research team and decided upon collectively. Articles were stratified by year of publication, national context (within the United States vs outside the United States), and by inclusion of low-income populations in their samples to examine trends. Figure 1 provides an illustration of the process used in the selection of articles for the systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach.
Table 1Summary of articles published from 1994 to 2014 included in systematic review that focused on factors influencing farmers’ market (FM) use (N=49)
For the data collection approaches, quantitative methods included surveys and dot surveys; qualitative methods included focus groups, ethnographic data, and interviews; and mixed methods included a combination of both qualitative and quantitative methods.
Study locations were determined as Western=Alaska, Hawaii, Washington, Oregon, California, Idaho, Nevada, and Arizona (n=5); Mountain Plains=Montana, Wyoming, Utah, Colorado, Kansas, Nebraska, North Dakota, South Dakota, Iowa, and Missouri (n=1); Southwest=New Mexico, Oklahoma, Texas, Arkansas, and Louisiana (n=2); Midwest=Minnesota, Wisconsin, Illinois, Indiana, Michigan, and Ohio (n=7); Southeast=Kentucky, Tennessee, North Carolina, South Carolina, Mississippi, Alabama, Georgia, and Florida (n=13); Mid-Atlantic=Pennsylvania, West Virginia, Virginia, New Jersey, Delaware, Maryland, and Washington, DC (n=4); Northeast=Maine, New Hampshire, Vermont, New York, Massachusetts, Rhode Island, and Connecticut (n=2); and Nationwide=across the United States (n=1).
a For the data collection approaches, quantitative methods included surveys and dot surveys; qualitative methods included focus groups, ethnographic data, and interviews; and mixed methods included a combination of both qualitative and quantitative methods.
b Study locations were determined as Western=Alaska, Hawaii, Washington, Oregon, California, Idaho, Nevada, and Arizona (n=5); Mountain Plains=Montana, Wyoming, Utah, Colorado, Kansas, Nebraska, North Dakota, South Dakota, Iowa, and Missouri (n=1); Southwest=New Mexico, Oklahoma, Texas, Arkansas, and Louisiana (n=2); Midwest=Minnesota, Wisconsin, Illinois, Indiana, Michigan, and Ohio (n=7); Southeast=Kentucky, Tennessee, North Carolina, South Carolina, Mississippi, Alabama, Georgia, and Florida (n=13); Mid-Atlantic=Pennsylvania, West Virginia, Virginia, New Jersey, Delaware, Maryland, and Washington, DC (n=4); Northeast=Maine, New Hampshire, Vermont, New York, Massachusetts, Rhode Island, and Connecticut (n=2); and Nationwide=across the United States (n=1).
Figure 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for systematic review of articles published from 1994 to 2014 that focused on barriers and facilitators of farmers’ market (FM) use.
Variety and Rigor of Existing Farmers’ Market Research
The 49 articles were published in a variety of journals, indicating an interdisciplinary interest in the topic of farmers’ market use. The disciplines represented included nutrition, health, agriculture, consumer sciences, community development, sociology, environmental sciences, and parks and recreation. The articles were based on analysis of quantitative research (n=30), qualitative research (n=10), and mixed methods research (n=9). A summary of the 49 articles is provided in Table 1.
Data in the articles were collected between 1997 and 2013, although 11 studies did not report dates of data collection. Most of the articles (65%) were focused on populations in the United States with the majority examining Southeastern (n=13), Midwestern (n=7), and Western (n=5) regions of the country. Two studies included cross-national comparisons. Those from outside the United States focused on populations from Europe (ie, United Kingdom, Italy, Belgium, Ireland, Sweden, and Czech Republic) (n=11), Canada (n=5), and New Zealand (n=1). Most of the articles (82%) included farmers’ market shoppers as the target population. Study populations included less often were farmers’ market vendors or staff, general population, primary food shoppers not using farmers’ markets, and food assistance recipients. The median sample size for these studies was 179 (range=12 to 3,250). The wide range in sample size is indicative of the different study designs employed, with qualitative studies including smaller sample sizes compared with quantitative studies. Geographic characteristics of the study context were reported in 80% of the studies with most (n=18) occurring in at least two geographic areas (eg, rural and urban). Among those conducted in only one geographic area, more occurred in urban areas (n=17) compared with rural (n=3) or suburban (n=1).
Information about the sample characteristics was reported inconsistently in the articles. Economic status of the study populations was reported in 59% of the articles, resulting in 20 studies where income of participants was not specified. Among those where income of the study population was specified (n=29), low-income populations were included in 19 studies (12 of these studies focused exclusively on low-income consumers; seven focused on two or more income categories, including low-income). Ten studies focused exclusively on middle- and high-income populations. No studies that included multiple income levels stratified their results by income. Sex was reported in 69% of the studies with all of these reporting women as the majority sex of participants. Race or ethnicity of the study participants was reported least frequently in 41% of the studies. Among articles reporting race or ethnicity, participants were identified as being majority white (n=13), black or African American (n=5), Native Hawaiian (n=1), or Latino (n=1).
Analysis of publications by year, stratified by US-based vs non–US-based research, revealed a substantial increase in publications in the United States over time (increasing from four studies in 2000-2004 to 23 studies in 2010-2014) coinciding with the increase in farmers’ market availability in the United States.
Among US-based studies, the proportion that included low-income populations increased over time from 25% for studies published during the period between 2000 and 2004 compared with 60.9% published during the period between 2010 and 2014. This same trend was not evident in studies based outside the United States; however, in general, few non–US-based studies specified income level of participants regardless of time. Analysis of the number of facilitators and barriers to farmers’ market use found in the studies by the five domains of nutritious food access (ie, economic, service delivery, spatial-temporal, social, and personal) revealed an overall trend among the 49 studies of facilitators being more commonly identified than barriers. However, in US-based studies, there was an increase in the proportion of barriers identified over time rising from 33.3% in published articles appearing between 2000 and 2004 to 43.1% in published articles appearing between 2009 and 2014 coinciding with increases in the number of studies that included low-income populations in their samples.
Overall, there was very limited use of common methods and metrics to assess factors associated with farmers’ market use. Six studies reported on the psychometric properties of the measures used in their analysis.
For each article, factors associated with farmers’ market use were examined. Findings in the articles were coded into one of five factors based on an existing framework of nutritious food access (ie, economic, service delivery, spatial, social, and personal).
These five factors accounted for all of the barriers and facilitators of farmers’ market use found in the literature. Findings are presented for each factor. The results first focus on the articles that included low-income populations in their sample (n=19) and then on the remaining articles that included high- and middle-income populations or unspecified income (n=30). Table 2 provides a summary of the findings.
Table 2Facilitators and barriers related to farmers’ market (FM) use based on systematic review of peer-reviewed literature published during the period from 1994 to 2014 (N=49)
Domain
Factors influencing FM use
Percentage of Studies Identifying Each Facilitator or Barrier
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