Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions.

OBJECTIVE: Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set. METHODS: We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups. RESULTS: Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category. CONCLUSIONS: Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Planting Seeds for Food Is Medicine: Pre-Implementation Planning Methods and Formative Evaluation Findings From a Multi-Clinic Initiative in the Midwest.

Food is medicine (FIM) initiatives are an emerging strategy for addressing nutrition-related health disparities increasingly endorsed by providers, payers, and policymakers. However, food insecurity screening protocols and oversight of medically-tailored food assistance programs are novel for many healthcare settings. Here, we describe the pre-implementation planning processes used to successfully engage federally-qualified health centers (FQHCs) across Kansas to develop new FIM initiatives. A Kansas-based philanthropic foundation facilitated pre-implementation planning for FQHCs over 17 months across 3 stages: 1) Community inquiry, 2) FIM learning event with invitation for FQHC attendees to request pre-implementation funding, and 3) Pre-implementation planning workshops and application assignments for FQHC grantees to develop a FIM implementation grant proposal. We evaluated satisfaction and perceived utility of these pre-implementation planning activities via post-workshop surveys and qualitative comparisons of FIM design components from pre-implementation and implementation grant applications. All 7 FQHCs attending the learning event applied for and were awarded pre-implementation planning grants; 6 submitted an implementation grant application following workshop completion. FQHCs rated pre-implementation support activities favorably; however, most clinics cited limited staff as a barrier to effective planning. As compared to pre-implementation planning grant proposals, all FQHCs elected to narrow their priority population to people with pre-diabetes or diabetes with better articulation of evidence-based nutrition prescriptions and intervention models in their final program designs. In the midst of a nationwide FIM groundswell, we recommend that funders, clinic stakeholders, and evaluators work together to devise and financially support appropriate pre-implementation planning activities prior to launching new FIM initiatives.

Associations of social determinants of health and childhood obesity: a cross-sectional analysis of the 2021 National Survey of Children's Health.

CONTEXT: Childhood obesity is a growing health problem in the United States, with those affected having an increased likelihood of developing chronic diseases at a younger age. Social determinants of health (SDOH) are known to influence overall health. Families who are of low socioeconomic status (SES) have also been shown to be more likely to experience food insecurity. OBJECTIVES: Our primary objective was to utilize the National Survey of Children's Health (NSCH) 2021 data to determine the current associations between childhood obesity and SDOH. Secondarily, we estimated the prevalence of select SDOH among children with obesity. METHODS: We conducted a cross-sectional analysis of 2021 NSCH to extract data related to the SDOH domains. We extracted sociodemographic variables to utilize as controls and constructed logistic regression models to determine associations, via odds ratios, between SDOH and childhood obesity. RESULTS: Within the binary regression models, children with obesity (≥95th percentile) were more likely than children without obesity to experience SDOH in all domains. After controlling for sociodemographic variables, children with obesity were significantly more likely to experience food insecurity when compared to children without obesity (adjusted odds ratio [AOR]=1.39; 95 % confidence interval [CI]: 1.13-1.17). CONCLUSIONS: In line with the current American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG), improving policies for nutrition programs and addressing the lack of access to nutritious foods may alleviate some food insecurity. Ensuring that children have access to sufficient nutritious foods is critical in addressing childhood obesity and thus decreasing risk of chronic disease.

Food Is Medicine for Individuals Affected by Homelessness: Findings from a Participatory Soup Kitchen Menu Redesign.

Health disparities among people experiencing homelessness are likely exacerbated by limited access to healthy, fresh, and minimally processed foods. Soup kitchens and shelters serve as essential food safety nets for preventing hunger in this population, and community interest is growing in the potential of "food is medicine" interventions to improve the mental and physical wellbeing of people who receive meals from these providers. This study describes our two-phase approach to first identify and prioritize nutrition needs within an urban soup kitchen community and then test and implement new recipes and menu guidelines to help the standard soup kitchen menu better align with those priorities. We began by first conducting a nutrition needs assessment, including a collection of intercept surveys from a convenience sample of soup kitchen guests to better understand their nutrition-related health needs, dental issues, food preferences, and menu satisfaction (n = 112), as well as a nutrition analysis of the standard menu based on seven randomly selected meals. Most respondents reported at least one chronic health condition, with depressive disorders (50.9%) and cardiovascular diseases (49.1%) being the most common. Nearly all guests requested more fruits and vegetables at mealtimes, and results from the menu analysis revealed opportunities to lower meal contents of sodium, saturated fat, and added sugars and to raise micronutrient, fiber, and omega-3 content. We then applied these nutrition needs assessment findings to inform the second phase of the project. This phase included the identification of new food inventory items to help support cardiovascular and mental health-related nutrition needs, taste test sampling of new healthy menu items with soup kitchen guests, and hands-on culinary medicine training to kitchen staff on newly-developed "food is medicine" guidelines to support menu transformation. All taste tests of new menu items received over 75% approval, which exceeded satisfaction ratings of the standard menu collected during the phase 1 needs assessment. Findings from this community-based participatory research project confirm the great potential for hunger safety net providers to support critical nutrition needs within this vulnerable population through strategic menu changes. However, more research is needed on the longitudinal impacts of such changes on health indicators over time.

Geographic and social economic disparities in the risk of exposure to ambient air respiratory toxicants at Oklahoma licensed early care and education facilities.

BACKGROUND: Early life exposures to hazardous air pollutants has been associated with adverse asthma-related outcomes. Neighborhood-level social and economic factors play an essential role in the distribution of hazardous air pollutants and children spend a substantial amount of time at early care and education (ECE) facilities. While the indoor air quality of these facilities has been described, particularly for criteria air pollutants such as volatile organic compounds and particulate matter, little is known about the ambient air quality of ECE facilities. OBJECTIVES: We conducted a cross-sectional study to estimate the ambient air quality of Oklahoma licensed ECE facilities and to explore associations between ambient air quality and select geographic predictors. METHODS: We estimated ambient air quality using the total respiratory hazard quotient from the National Air Toxics Assessment according to the geographical location of licensed Oklahoma ECE facilities (N = 3184). We then determined whether urban and rural ECE facilities' air respiratory toxicant exposure risk differed by ECE facilities' neighborhood-level social and economic inequities including: 1) racial-ethnic minority community, 2) neighborhood socioeconomic status, and 3) residential segregation. RESULTS: Urban ECE facilities in Hispanic segregated counties were five times more likely to be at risk of high air respiratory exposure, adjusted for integrated urban counties (p < 0.0001, 95% CI [3.824, 7.699]). Rural ECE facilities in African American segregated counties were nine times more likely to be at risk of high air respiratory toxicant exposure, adjusted for integrated rural counties (p < 0.0001, 95% CI [5.641, 15.928]). CONCLUSION: We found geographically and socially disparate patterns of higher exposures to ambient air respiratory toxicants at Oklahoma ECE facilities. Safer siting policies and interventions are needed to mitigate air respiratory toxicant exposures, which may help to reduce asthma control disparities and improve respiratory health outcomes in Oklahoma ECE facilities.

Community Health Improvement Plans: An Analysis of Approaches Used by Local Health Departments.

CONTEXT: The Public Health Accreditation Board requires accredited local health departments (LHDs) to complete community health improvement plans (CHIPs). Evidence suggests that participatory planning frameworks, cross-sector collaboration, social determinants of health (SDOHs), and steering organizations are integral to effective public health planning. However, little is known about the degree to which LHDs incorporate these aspects during the CHIP process. OBJECTIVES: To describe the use of planning methods, SDOHs, cross-sector partnerships, and steering organizations during the CHIP development process among nationally accredited LHDs and to identify whether LHD jurisdictional size or region is associated with differences in use. DESIGN: The most recent CHIPs from 93% of all nationally accredited LHDs (n = 195) were qualitatively reviewed and numerically coded for each of the planning components to calculate frequency and degree of use. Differences in use of each component by LHDs' jurisdictional size and region were tested using the chi-square test. MAIN OUTCOME MEASURE: Use of CHIP planning frameworks, SDOH inclusion, cross-sector partnerships, and steering organizations. RESULTS: One-half of LHDs (53%) reported use of Mobilizing for Action through Planning and Partnerships, but nearly one-fourth of LHDs did not use any planning framework. LHDs with a large jurisdictional size (>500 000) were significantly more likely to include SDOHs to a high degree than LHDs with mid- (100 000-499 999) to small- (<99 999) jurisdictional size (P < .01). Similarly, large LHDs were more likely to include cross-sector partners except for the category community members, which were rarely (10%) included. Mid-sized LHDs were more likely to lead the CHIP steering committee (61%) than small (29%) and large (9%) LHDs (P < .01). Differences in use of the 4 components by region were less significant. CONCLUSIONS: Jurisdictional size, rather than region, was more strongly associated with LHD approaches to CHIP development. More studies are needed to determine how differences influence CHIP implementation and impact.

Promoting nutrition equity for individuals with physical challenges: A systematic review of barriers and facilitators to healthy eating.

Impaired mobility is the most common form of functional disability in the US, affecting one out of every sixteen working-age adults. Little is known about the barriers to and facilitators of healthy eating among people with impaired mobility (PWIM), who are at increased risk for diet-related chronic disease. The pathways by which impaired mobility influence dietary intake are unclear, yet likely involve a complex interplay between structural determinants of health and individual factors. To help advance nutrition equity initiatives for PWIM, this systematic review aimed to qualitatively synthesize factors associated with dietary intake across four levels of ecologic influence. An interprofessional team devised a comprehensive search strategy to identify these factors among working-age (18-64 years) PWIM. We queried Ovid MEDLINE, Web of Science, Scopus, and Embase via Ovid for articles published between January 1, 1990 and April 25, 2021. Twelve studies met our review criteria. We classified factors within one of four ecologic levels of influence: individual, social, environmental, and policy/program. Most studies disproportionately reported on personal level factors of influence, with less information on other levels of influence. This systematic review is an important first step for informing the design of evidence-based strategies to support healthy eating among PWIM. However, it also reveals a wide chasm in the needed information to adequately bridge structural determinants of this nutrition divide. More studies are needed that include rigorous measures of dietary intake and that aim to elicit how social, environmental, and policy-level factors contribute to dietary disparities among PWIM.

A Nutrition Environment Measure to Assess Tribal Convenience Stores: The THRIVE Study.

In rural American Indian (AI) communities, where supermarkets are rare, tribally owned and operated convenience stores are an important food source. Food environment measures for these settings are needed to understand and address the significant diet-related disparities among AIs. Through a tribal-university partnership that included tribal health and commerce representatives from two Native Nations in rural southeastern Oklahoma, we developed the Nutrition Environment Measures Survey for Tribal Convenience Stores (NEMS-TCS) to inform the development and evaluation of a healthy food retail intervention. The NEMS-TCS assessed four scored domains of the rural convenience store food environment-food availability, pricing, quality, and placement-and included 11 food categories that emphasized ready-to-eat food items. Trained raters administered the NEMS-TCS using a sample of 18 rural convenience stores (primarily ranging between 2,400 and 3,600 square feet). We assessed interrater reliability with kappa statistics for dichotomized variables and intraclass correlation coefficients (ICC) for continuous variables. NEMS-TCS demonstrated high inter-rater reliability for all food categories (>85% agreement), subscores (ICC = 0.73-1.00), and the total score (ICC = 0.99). The NEMS-TCS responds to recent calls for reliable measures for rural food environments and may be valuable for studying food environments of large convenience stores in other Native Nations as well as other rural settings.

Diabetes and Obesity Associated with Poor Food Environments in American Indian Communities: the Tribal Health and Resilience in Vulnerable Environments (THRIVE) Study.

BACKGROUND: American Indians (AIs) have significantly higher rates of diet-related chronic diseases than other racial/ethnic groups, and many live in environments with limited access to healthy food. OBJECTIVE: As part of the Tribal Resilience in Vulnerable Environments (THRIVE) study, we examined the relations between the perceived food environment, utilization of food retailers, fruit and vegetable intake, and chronic diseases, including obesity, hypertension, and type 2 diabetes among AI adults. METHODS: Through a community-based participatory research partnership, we surveyed a cross-sectional sample of 513 AIs living within the Chickasaw Nation and the Choctaw Nation of Oklahoma. RESULTS: Only 57% of participants reported that it was easy to purchase fruits and vegetables in their town, and fewer (35%) reported that available fruits and vegetables were of high quality. Additionally, over half (56%) reported traveling ≥20 miles round trip to shop for food. Few participants met the recommended daily intake for fruit (44%) or vegetables (25%). Obesity (55%), hypertension (49%), and diabetes (25%) were commonly reported. Obesity was significantly higher among participants who reported that the price of fruits and vegetables were cost-prohibitive (prevalence proportion ratio (PPR): 1.24; 95% CI: 1.02, 1.50) and those who shopped frequently for food at nontraditional food retailers, such as Dollar Stores (PPR: 1.35; 95% CI: 1.08, 1.69) and small markets (PPR: 1.38; 95% CI: 1.02, 1.86). Diabetes was significantly higher among participants who frequently shopped at convenience stores/gas stations (PPR: 2.26; 95% CI: 1.22, 4.19). CONCLUSIONS: Our study found that the use of nontraditional food retailers, including convenience stores, gas stations, and Dollar Stores, as a regular source of food was associated with obesity and diabetes. These results underscore the importance of interventions to improve rural Tribal food environments. Healthy retail interventions in nontraditional retail settings, such as those implemented through the THRIVE study, may contribute to reducing AI health disparities.

Nutrition-Focused Food Banking in the United States: A Qualitative Study of Healthy Food Distribution Initiatives.

BACKGROUND: Nutrition-focused food banking is broadly defined as organizational and programmatic efforts to address nutrition-related health disparities among charitable food clients. Additional information is needed to systematically describe how US food banks, as key influencers of the charitable food system, are working to advance nutrition-focused food banking initiatives in their communities. OBJECTIVE: Our aim was to describe food bank leadership-identified organizational strategies, "best practices," and innovative programs for advancing nutrition-focused food banking in the United States. DESIGN: We conducted semi-structured qualitative interviews to elicit information about the nutrition-focused food banking practices and processes being employed by US food banks. PARTICIPANTS/SETTING: Participants comprised a purposive sample of food bank executives (n=30) representing a diverse selection of food banks across the United States. Interviews were conducted between April 2015 and January 2017 at national food bank conferences. ANALYSIS: Two researchers independently reviewed transcripts to identify themes using code-based qualitative content analysis. RESULTS: Executive leader descriptions of specific strategies to support nutrition-focused food banking centered primarily around the following four major themes: building a healthier food inventory at the food bank; enhancing partner agency healthy food access, storage, and distribution capacity; nutrition education outreach; and expanding community partnerships and intervention settings for healthy food distribution, including health care and schools. CONCLUSIONS: Study findings indicate that food banks are implementing a variety of multilevel approaches to improve healthy food access among users of the charitable food system. Further evaluation is needed to assess the reach, scalability, and sustainability of these various approaches, and their effectiveness in reducing determinants of nutrition-related health disparities.

Characteristics of Households of People With Diabetes Accessing US Food Pantries: Implications for Diabetes Self-Management Education and Support.

PURPOSE: The purpose of this study is to explore the associations between food insecurity (FI) and coping strategies of relevance to diabetes self-management among households of people with diabetes (HHDM) who access US food pantry programs. METHODS: The authors conducted a secondary data analysis of HHDM accessing US food pantry programs from the Hunger in America 2014 study (n = 16 826). Weighted analyses included descriptive statistics for household sociodemographics, food pantry service utilization, FI, and coping behaviors. The authors used chi-square and logistic regression to estimate the relationship between FI and coping behaviors. RESULTS: Nearly one-half of HHDM reported visiting food pantries at least 6 times in the past year. Most HHDM were FI, with the majority experiencing the most severe form of FI. Over one-fifth of households reported lacking health insurance. The majority of HHDM reported purchasing inexpensive unhealthy foods to ensure household food adequacy, and many reported watering down food and beverages. The odds of reporting these behaviors significantly increased as FI worsened. CONCLUSION: Food pantries represent an opportunity for the delivery of community-based diabetes self-management education and support programs. These programs should be adapted to address population barriers to self-management and to support access to healthful foods and medical care.

Charitable food as prevention: Food bank leadership perspectives on food banks as agents in population health.

Food banks (FBs) and their partner agencies play important food access roles in nearly every US community. While FB missions have historically emphasized hunger alleviation, stakeholders are increasingly expressing interest in leveraging these community assets to promote health. We conducted semi-structured interviews with US FB executives (n=30) to explore their perspectives on the evolving role of FBs in community health, and how these perspectives relate to organizational efforts to distribute healthier foods, including fruits and vegetables (F&V). All but one executive reported actively working to increase F&V distribution; however, fewer executives had implemented nutrition policies. Executives reporting higher F&V distribution more often described health as central to their organization's mission and perceived charitable food program clients as being at high risk for chronic disease. FB leadership recognition of health and hunger as interrelated community issues may have direct implications for FB strategic planning, distribution practices, and policies related to F&V.

Food choice considerations among American Indians living in rural Oklahoma: The THRIVE study.

In rural American Indian (AI) communities, access to affordable, healthy foods is often limited. Understanding AI food choice considerations when selecting foods, such as sensory appeal, cost, or health, is an important yet understudied topic for eliminating persistent AI health disparities. In partnership with the Chickasaw Nation and Choctaw Nation of Oklahoma, we administered a modified version of the Food Choice Values (FCV) Questionnaire to a cross-sectional sample of 83 AI patrons shopping at tribally-owned convenience stores ≥3 times per week. The FCV Questionnaire uses 25 items to assess eight FCV subscales related to buying and eating food, including sensory appeal; safety; accessibility; convenience; health/weight control; organic; tradition; and comfort. We compared mean scores for each FCV subscale by demographic groups using t-tests and ANOVA. We used confirmatory factor analysis (CFA) to examine how well the data from this population fit FCV subscale constructs. We then used cluster analysis, MANOVA, and discriminant analysis to characterize distinct segments of the population based on patterns of FCV endorsement. Appeal, safety, and access FCVs were most strongly endorsed across the sample. Prioritization of FCVs varied by age, gender, income, and education. Our cluster analysis identified four groups, or segments, each with distinct patterns of FCV endorsement: limited endorsement of any FCVs (23.3%); safety and sensory appeal (32.9%); health/weight control (17.8%); and broad endorsement of FCVs (26.0%). These groups varied by age and employment status. Findings from this analysis informed the design and implementation of a healthy retail intervention comprised of new healthful foods and beverages, product placement and marketing strategies within four tribally-owned and operated convenience stores. Public health interventions aimed at reducing nutrition-related disparities in rural AI populations may benefit from assessing food choice considerations.

SNAP-Based Incentive Programs at Farmers' Markets: Adaptation Considerations for Temporary Assistance for Needy Families (TANF) Recipients.

OBJECTIVE: To describe the design, implementation, and consumer response to a coupon-style intervention aimed to increase Supplemental Nutrition Assistance Program (SNAP) use at a farmers' market (FM) among Temporary Assistance for Needy Families (TANF) participants. DESIGN: A quasi-experimental trial to evaluate redemption response to 2 coupon interventions; baseline surveys characterized coupon redeemers and non-redeemers. SETTING: Urban. PARTICIPANTS: The TANF recipients were assigned to either a plain (n = 124) or targeted marketing coupon intervention (n = 130). INTERVENTION(S): Both groups received 10 $2 coupons to double fruit and vegetable SNAP purchases at the FM. The targeted marketing group also received an oral presentation designed to reduce perceived barriers to FM use. MAIN OUTCOME MEASURE: Coupon redemption. ANALYSIS: The researchers used t tests and chi-square/Fisher exact tests to examine associations between redeemers and non-redeemers; logistic regression was used to adjust for the intervention. RESULTS: No male and few female participants redeemed coupons (6.3%). Among women, those with knowledge of vegetable preparation were 3 times more likely to redeem coupons than were those with little or no knowledge (odds ratio = 3.77; 95% confidence interval, 1.03-13.77). CONCLUSIONS AND IMPLICATIONS: Stand-alone coupon incentive programs may not be a high-reach strategy for encouraging FM use among the population using TANF. Complementary strategies to build vegetable preparation knowledge and skills are needed.

Cardiovascular Disease Risk Factors and Health Outcomes Among American Indians in Oklahoma: the THRIVE Study.

INTRODUCTION: Limited available data document higher prevalences of cardiovascular disease (CVD) risk factors and health outcomes among American Indians (AIs) compared to other racial/ethnic groups. METHODS: As part of a randomized control trial to improve tribal food and physical activity environments, our tribal-academic partnership surveyed a cross-sectional sample of American Indian adults (n = 513) to assess the prevalence of type 2 diabetes, obesity, hypertension, tobacco use, physical activity, and vegetable and fruit intake. Surveys were collected from April through May 2015. We used logistic regression to examine the association between CVD-related risk factors and health outcomes. RESULTS: The prevalence of CVD-related outcomes was high, ranging from 25% for diabetes to 75% for low vegetable intake. The prevalence of diabetes, obesity, and hypertension tended to be higher among participants with any tobacco use compared to no tobacco use, but findings were not statistically significant. The prevalence of diabetes (prevalence ratio 2.1, 95% CI 1.4-3.2) and obesity (prevalence ratio 1.5, 95% CI 1.2-1.8) was higher among participants with low physical activity levels compared to recommended physical activity levels. CONCLUSIONS: CVD risk factors and health outcomes persist among American Indians even as some risks (e.g., smoking) appear to be stabilizing or even declining in the general US population. Efforts to include American Indians in national health surveys, implement broad reaching environmental and policy interventions, and address the social determinants of health are critical to the elimination of these disparities.

Farmers' markets and the local food environment: identifying perceived accessibility barriers for SNAP consumers receiving temporary assistance for needy families (TANF) in an urban Oklahoma community.

OBJECTIVE: To examine barriers to farmers' market (FM) use by Supplemental Nutrition Assistance Program (SNAP) consumers receiving Temporary Assistance for Needy Families. DESIGN: Focus groups. SETTING: An urban community in Oklahoma. PARTICIPANTS: Supplemental Nutrition Assistance Program beneficiaries receiving Temporary Assistance for Needy Families (n = 64 across 8 focus groups). PHENOMENON OF INTEREST: Perceptions about FM foods and barriers to FM use. ANALYSIS: Transcript-based content analysis using the 5 dimensions of access framework. RESULTS: Few participants ate fresh produce regularly and most appreciated the convenience of shopping at a supermarket. Farmers' markets were not perceived as available or accommodating to shopping needs and affordability and acceptability concerns were expressed. Few were aware of FMs that accepted SNAP. Emerging themes suggested residential segregation and cultural barriers to FM use. CONCLUSIONS AND IMPLICATIONS: Farmers' market managers, community nutritionists, and researchers should develop interventions that correct common misperceptions about FM products, minimize access barriers, and increase awareness of SNAP payment options. Residential segregation and cultural barriers may have a role in FM use and should be explored further.