Social Determinants of Health: Fruit and Vegetable Incentive Programs

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends fruit and vegetable incentive (FVI) programs for households with lower incomes based on strong evidence of effectiveness in reducing household food insecurity and increasing household fruit and vegetable consumption.

Programs in which incentives were provided to participants who were at risk for or had diet-related health conditions improved blood glucose as measured using A1c levels.

Fruit and vegetable incentive programs are expected to improve health equity across the United States by improving affordability and access to healthier foods for households with lower incomes.

The CPSTF also finds fruit and vegetable incentive programs to be cost-effective. 

The full CPSTF Finding and Rationale Statement and supporting documents for Social Determinants of Health: Fruit and Vegetable Incentive Programs are available in The Community Guide Collection on CDC Stacks.

Intervention

Fruit and vegetable incentive programs offer people financial incentives to purchase fruits and vegetables. These programs aim to improve affordability and access to fruits and vegetables for participants with lower incomes. Examples include produce prescriptions, bonus dollars, market bucks, produce coupons, and nutrition incentives.

People can use incentives to help pay for fruit and vegetables at various venues, such as farmers’ markets, mobile markets, or grocery stores. Incentive models may include:

  • Point-of-sale discounts (i.e., percentage off regular price)
  • Rebates (i.e., cash back for future purchases)
  • Matches (i.e., money tied to the dollar amount spent)
  • Subsidies (i.e., a fixed amount of money available to purchase fruits and vegetables)

Programs may be implemented by community-based organizations; local, state, territorial, or tribal governments; or health systems. Programs may be carried out by community-based organizations; local, state, territorial, or tribal governments; or health systems. Programs may also provide participants with nutrition education, such as cooking lessons or demonstrations.

The impact of the federal nutrition assistance programs such as the Supplemental Nutrition Assistance Program (SNAP); the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and the Food Distribution Program on Indian Reservations (FDPIR) are outside the scope of this review.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 30 studies (search period database inception through February 2023) conducted in the United States.

Study Characteristics

  • Study designs included single group pre-post (18 studies), randomized control trial (5 studies), pre-post with concurrent comparison group (5 studies), retrospective cohort (1 study), and time series with no comparison group (1 study)
  • All of the included studies were conducted in the United States (30 studies)
  • Over half of the included studies evaluated fruit and vegetable incentive programs in urban areas (16 studies). The remaining studies were conducted in a combination of urban, suburban, and rural settings (9 studies), rural areas alone (4 studies), or tribal lands (1 study)
  • Studies that collected information on sex (25 studies) reported most of their participants were female (72%)
  • Studies that collected information on participants’ self-identified racial or ethnic background reported that 37% participants were Hispanic or Latino (24 studies), 28% were Black or African American (26 studies), 27% were White (25 studies)
  • All studies included participants with lower income (30 studies)
  • In studies reporting participation in the Supplemental Nutrition Assistance Program (SNAP; 14 studies), 55% of participants received SNAP benefits
  • In studies reporting participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC; 11 studies), 16% of participants received WIC benefits
  • The median participant age was 42 years (22 studies)
  • Studies included programs offered through local government or community organizations (16 studies) and health care providers (13 studies), or a mix of both (1 study)
  • Studies included incentives that were redeemed in farmers markets (16 studies), grocery stores (3 studies), or a mix of both (9 studies)
  • The median program duration was 6 months (22 studies)

Summary of Results

Evidence from the systematic review’s included studies showed that fruit and vegetable incentive programs reduced household food insecurity and increased the consumption of these foods. Evidence also showed that programs providing incentives to participants at risk for or with diet-related health conditions resulted in improved blood glucose levels, as measured by A1c levels. Across the studies, the programs:

Reduced household food insecurity:

  • Percent who were food insecure decreased by 18 percentage points (7 studies)

Increased fruit and vegetable consumption:

  • Servings: Increased by 1.10 servings per day (5 studies)
  • Cups: Increased by 0.13 cups per day (8 studies)
  • Number of times: Increased by 0.49 times per day (5 studies)

Improved blood glucose measures (among participants at risk for or with diet-related health conditions):

  • Hemoglobin A1c levels decreased by 0.64 percentage points (6 studies)

Summary of Economic Evidence

The economic evidence shows fruit and vegetable incentive (FVI) programs are cost-effective.  

CPSTF based its economic assessment on eight studies (published through April 2024), three reporting on intervention cost and five reporting on cost-effectiveness (whether the programs provided good value for the money). The review reports values in 2023 U.S. dollars. Only good- or fair-quality intervention cost and cost-effectiveness estimates were retained in the review; limited-quality estimates were excluded.  

Study Characteristics  

  • Types of incentives: The most studied incentive was rebates (4 studies), but discounts, subsidies, and matched funds were also assessed.  
  • Program locations: Programs took place in grocery stores, farmers’ markets, and mobile markets. 
  • Who was served: Most studies focused on people receiving SNAP benefits (6 studies). Others included food-insecure households and people with chronic diseases.  

Economic Findings  

Program Costs:  

  • SNAP rebate programs cost about $4 to $23 per household each month (1 study).  
  • Produce prescription programs cost about $16 per household each month (1 study). 
  • Cost-Effectiveness: Five studies examined whether these programs improve health at a reasonable cost. On average, the median cost for each additional year of healthy life gained (cost per QALY gained) was $18,050 over a lifetime. This estimate and a tested range of results were well below the $150,000 CPSTF benchmark for cost-effectiveness, indicating these programs are considered a good value. 

Applicability

Based on results from this systematic review, the finding should be applicable to people with lower incomes in urban, suburban, and rural areas throughout the United States, regardless of sex, race or ethnicity, age, or educational level. The findings are relevant regardless of the organization that provided the program, the incentive redemption venue, whether programs included other intervention components in addition to incentives, the incentive frequency and model, and the duration of the intervention.

Evidence Gaps

  • What is the long-term impact of FVI programs and how can improvement in outcomes be sustained after the program ends?
  • How does effectiveness vary among population groups (e.g., children, recipients of SNAP or WIC, people with or at risk for diet-related health conditions)?
  • How can programs best be tailored to participants to improve incentive redemption and program effectiveness?

Remaining questions for research and evaluation identified in this review include:

  • How can researchers use consistent dietary measures for fruit and vegetable consumption to enable comparisons across studies?
  • How does the seasonality of farmers markets impact participants’ fruit and vegetable purchases and consumption? How can improvements in outcomes be sustained during the off-season?
  • What is the total incentive amount provided by programs? Does program effectiveness vary by the amount provided?
  • Does program effectiveness vary by the incentive model? Specifically, do point-of-sale discounts and rebates work as well as subsidies and matches?
  • What are the best strategies for recruiting people who are eligible for nutritional assistance programs (e.g., SNAP), but not enrolled?

Economic Evidence Gaps

CPSTF found the intervention was cost-effective, meaning the health benefits justified the costs. However, there was not enough evidence to assess other economic outcomes. The following questions are proposed as a priority for economic research and evaluation: 

  • What is the intervention cost of FVI programs? 
  • Do the monetized benefits of FVI programs exceed the intervention cost? 
  • Do economic outcomes of FVI programs differ by rural and urban locations? 

Remaining questions for research and evaluation identified in the economic review include the following: 

  • Does cost-effectiveness of FVI programs vary by the type of incentives? 
  • Do economic outcomes of FVI programs vary by type of commercial vendor? 

Implementation Considerations and Resources

Program participation and retention may be improved by:

  • Tailoring the program so that it carefully considers the culture and context of specific populations (Saxe-Custack et al. 2021, Jones et al. 2020)
  • Offering additional program components such as cooking demonstrations, grocery store tours, and activities for children (Anliker et al. 1992, Fertig et al. 2021, Bowling et al. 2016)
  • Including reinforcing messages about the benefits of increased fruit and vegetable consumption from healthcare providers in programs that offer produce prescriptions (Cavanagh et al. 2017)

Incentive use may be improved by:

  • Identifying redemption sites that are accessible to participants to reduce distance and transportation barriers (Bartlett et al. 2014, Veldheer et al. 2021)
  • Providing participants with information about how incentives work, which items are eligible for redemption, and where incentives can be redeemed (Atolye et al. 2021, Vericker 2019)
  • Providing more flexibility to participants in terms of where incentives can be redeemed

Other implementation considerations include:

  • Fruit and vegetable incentive programs may have a more significant impact in regions and states with higher rates of household food insecurity (Rabbitt et al. 2023)
  • Engaging with community partners (e.g., faith communities, community-based organizations) in program design and recruitment to improve program implementation (Fertig et al. 2021, Lyonnais et al. 2022)
  • Supporting participants after the program has ended so they may sustain behavior change without financial incentives
  • Providing implementers with access to technological tools to improve tracking of participants’ incentive use and products purchased

There are several publicly available resources that provide guidance on fruit and vegetable incentive program implementation:

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.