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Health Bucks

Evidence Summary

Underlying Logic:
High prices and limited access to fresh produce are identified barriers to eating healthy in low-income communities.  Health Bucks, which are $2 coupons, aim to address these barriers by incentivizing the purchase of local, fresh produce in farmers’ markets. The distribution/redemption of Health Bucks coupons increases purchasing power and ultimately improves dietary intake.

Strategies Used1:
The Health Bucks are distributed to SNAP participants and residents of low-income neighborhoods to incentivize their purchase of fresh produce, an example of pricing strategies to favor healthy foods and beverages.

The Health Bucks initiative employs the evidence-based strategy changing access and availability to favor healthy foods and beverages by encouraging an increase in the number of farmers’ markets that set up in low-income neighborhoods. Furthermore, the farmers/vendors offer increased availability of fresh produce options for neighborhood consumers to purchase.

Evaluation Outcomes

CDC contracted with Abt Associates to evaluate the NYC Health Bucks Initiative. In 2012, Abt issued an Evaluation Report that included both process and outcome evaluation. Center TRT used the Abt Report as the basis for this review and for the decision to disseminate Health Bucks as a practice-tested intervention.

Abt Associates began with extensive work to prepare for both the process and outcome evaluation of the program. In addition, interviews/group discussions and surveys were carried out with a broad range of stakeholders, including farmers/vendors, neighborhood residents, and consumers shopping at farmers’ markets.

Process Outcomes

Data collection methods included telephone interviews with farmers/vendors selling produce at NYC Health Bucks farmers’ markets (n=6) and on-site survey of vendors working at farmers’ markets stalls/stands (n=141).

Overall, farmers/vendors were satisfied with the Health Bucks program and didn’t find it complicated to implement.  They felt Health Bucks provided them with additional revenue; however, the evaluation couldn’t determine specific impact of the Health Bucks program relative to other incentive programs, such as SNAP.  As a result of the Health Bucks program, farmers/vendors believed they were likely to sell more fresh fruits and vegetables and indicated that the six weeks redemption timeline was acceptable/not burdensome.

When possible, Health Bucks were distributed at farmers’ markets accepting SNAP benefits via the EBT system. Wireless EBT terminals have to be available for SNAP participants to use their benefits, and prior to 2010, limited EBT terminals were a major barrier to farmers’ markets participation.  In the same year, funding was provided to address this concern; additionally, mini-grants were funded to support staff to operate EBT terminals.  However, the mini-grants were time-limited, thus in the future, EBT operation could be a barrier to adoption of Health Bucks program across other farmers’ markets

Data collection methods included focus groups and on-site point-of-purchases surveys (on-site point-of-purchase surveys with farmers’ market shoppers n=2,287).

Results of program awareness in groups targeted by Health Bucks were: 

  • 33% of District Public Health Office-area (DPHO) SNAP participants were aware of the Health Bucks program,
  • 31% of DPHO-area lower-income residents were aware of the program, and
  • Approximately 2/3 of both these groups reported using Health Bucks

Survey of DPHO-area neighborhood residents (telephone survey n=1,025):

  • Approximately 1/5 of residents surveyed were aware of the Health Bucks program.  Of those, approximately 2/5 reported using Health Bucks.
  • 1/2 of those who indicated using Health Bucks said they obtained them with EBT benefits at the market
    • About ¼ obtained them from markets as part of a promotion
    • 15% received them from local community-based organizations (CBOs)
    • 13% of Health Bucks users said they purchased items other than fruits and vegetables with the coupons.  However, it is unclear whether this is genuine improper use or if users confused Health Bucks with other incentive programs, like SNAP or WIC.

Community-based Organizations (CBOs):

  • CBOs were surveyed about the application process to participate in the Health Bucks program and found it to be acceptable/not difficult.
  • Nearly all CBOs paired Health Bucks distribution with nutrition programming.

Effectiveness Outcomes

  • Increase in number of participating farmers’ markets coincided with Health Bucks program introduction
    • In 2005, 15 farmers in 5 markets participated.
    • In 2010, the numbers increased to 81 farmers in 60 markets.
  • Increase occurred each year in the number of Health Bucks coupons distributed at farmers’ markets and by community organizations
    • In 2005, 3,000 Health Bucks coupons were distributed.
    • In 2010, the number increased to 138,930 coupons.
    • CBOs distribute ~30% of coupons while 71% are issued as an incentive with SNAP/EBT benefits at markets. 
  • Increase occurred each year in the number of Health Bucks redeemed by farmers
    • Redemption rates increased from 25% (in 2005) to 83% (in 2010). 
  • Increase in purchase and consumption of fresh fruits and vegetables in low-income populations
    • While there is a limitation in the quality of these data, Health Bucks users are more likely to report increase in fruit/vegetable consumption today compared to last year.
    • Farmers’ market shoppers are more likely to consume 5/more servings of fruit/vegetables, but no difference based on Health Bucks users.
    • No difference in perceived access to fruit/vegetables for varying levels of participation in Health Bucks. 
  • Perceived and actual benefits by:
    • Farmers/vendors
      • Participating farmer revenues increased over last 5 years from ~$200 (in 2005-07) to ~$2,800 (in 2010).
      • Market managers felt that Health Bucks attracted farmers to their markets and increased overall business.
      • Consumers and Residents
        • Consumers believed Health Bucks had significant impact on their purchasing and eating behavior and contributed to increased knowledge/awareness of preparing fruits/vegetables.
        • Majority of neighborhood residents reported that Health Bucks made them more likely to shop at farmers’ markets and buy more fruits/vegetables.

1 A full description of the intervention strategies used can be found here with references to the sources of evidence to support the strategies.