Consuming fruits and vegetables (FV) regularly is an important part of a healthy diet. Previous studies have shown an inverse association between FV intake and chronic disease development.¹ Accordingly, the Dietary Guidelines for Americans (2015) recommends that people consume at least 2.5 cups of vegetables and 2 cups of fruits daily, based on a general 2000-kcal/d diet.² However, despite the scientific support for regular FV consumption and concentrated efforts to communicate and educate consumers to consume more FV, the average American adult eats well below recommended intakes, and consumption is even lower among low-income populations.^3,4

Many factors contribute to low FV intake; however, among low-income individuals, lack of knowledge about healthy foods, lack of availability and access to FV, poor produce quality, and budget constraints are the most common barriers.^5–11 Cost of FV and income level are particularly influential on FV purchases, even more so than educational level,¹¹ emphasizing the importance of budget when making FV purchases.

In addition to the aforementioned factors, attitudes and beliefs relevant to FV, such as farming practices or fresh versus processed, can influence perceptions about FV impacting purchasing intention and intake.^12,13 Within the last 2 decades, interest in farming practices and, particularly, organic food has grown remarkably as consumers and marketers react to popular media about the health and environmental benefits of consuming organic products.¹⁴ Organic food sales in the United States has grown dramatically from $6 billion in the year 2000 to $28.4 billion in the year 2012, and FV accounted for 43% of US organic food sales.^15,16 Current media trends promote organic food, particularly organically grown fresh FV. Communications are focused on superior health benefits of organically grown FV and excessive pesticide residues of conventionally grown produce. These promotional communications successfully convince consumers to purchase organic FV by way of influencing people's perceptions and beliefs about organic FV relative to conventionally or nonorganically grown produce. People perceive organic FV as healthier and/or better for them compared with eating conventionally/nonorganically grown FV.^14,17 Likewise, confusion and fear regarding conventionally grown FV associated with pesticides have also been reported.^17,18 A major concern, however, is how these types of communications may be impacting FV intake in populations that cannot purchase organic FV, because of lack of accessibility, budget constraints, or other barriers.

Whereas previous research has assessed preferences, including reasons underlying those preferences, for choosing organically versus conventionally produced products in higher-income consumers,^18–20 relatively little research has directly explored the perceptions and attitude of low-income individuals on conventional versus organic FV. Therefore, the purpose of this study was to gain a better understanding of the knowledge and perceptions, attitudes, and beliefs about organic and conventionally grown produce in low-income shoppers and, furthermore, to examine whether modest adjustments of income level would impact these variables. In addition, we tested purchasing intentions of FV between the low-income groups to assess potential purchasing differences based on type (organic or conventional) but also to assess purchasing intention of any type of FV after reading informational statements about growing practices typically read or heard through various media outlets. The role of purchase intention on purchasing behavior¹⁹ and actual intake^12,21 is well recognized. Therefore, we used purchasing intention as a surrogate for potential shifts in purchasing behavior and intake. The study builds upon published work providing information from more than 500 primary household shoppers in and around Chicago, Illinois, and how attitudes and perceptions and purchasing intention of FV are associated with small differences in (low) income level.

METHODS

Survey Distribution

The study procedures and survey were approved by the institutional review board of the Illinois Institute of Technology, a private university in Chicago, Illinois. All participants provided written informed consent via the institutional review board–approved consent form before study participation. After completing a 6-question screening questionnaire, eligible participants were provided a survey questionnaire to be completed in-person or online. Participants who completed the survey in-person sat at a designated quiet area of the recruitment center. Online participants completed surveys via a link to a designated Web site.

Study Population

Six hundred eighteen (N = 618) interested participants residing in the greater Chicago, Illinois area, met the eligibility criteria and took the survey, including 261 in-person and 357 online. Inclusion criteria required participants to be 18 years or older, have a low income (at or less than 250% above the poverty level [PL] based on the poverty guideline as established by the US Department of Health and Human Services for determining poverty status²²), be the person responsible for the household grocery shopping, and purchase groceries at least once per month.

Previous work has examined FV intake across wide income levels ranging from $1200 per month to greater than $5000 per month.^4,23 To the best of our knowledge, no previous research has assessed FV perceptions and purchasing intent across income levels; and moreover, whether narrow income differences within low-income groups would be associated with differences in FV attitudes and purchasing intention. Therefore, participants for this study were categorized into 1 of 2 low-income levels: those with a household income level at or less than 150% above the PL (Lo150, n = 339) or those with a household income level between 151% and 250% above the PL (Lo250, n = 171). Income level criteria were determined based on eligibility criteria for federal assistance, medical, and community programs. Programs that have similar criteria are the Low Income Subsidy Program (150% above PL—a benefit for Medicare part D participants), Women, Infants and Children Program (185% above PL), Energy Saving Assistance Program (200% above PL), and free health clinics in the Chicago area (250% above PL). Generally, income levels higher than 250% above PL do not meet the eligibility of most public services. All questionnaires were verified for completeness and clarity. Of the 618 participants' survey questionnaires, 510 were evaluable.

Survey Questionnaire

The survey consisted of 53 questions in total and included open-ended, multiple choice and ranking options using 5-point Likert scales. Surveys were provided in English, Spanish, and Chinese and translated by native speakers. The survey asked questions to extract information regarding low-income shoppers: (1) FV purchasing behavior and factors influencing their FV purchases, such as cost, food safety, and nutrition; (2) their perceptions, attitudes, and beliefs about organic and conventional FV, including awareness of terms and issues; and (3) their purchasing intentions of FV. In addition, a series of questions were asked related to participants' views on credible sources for food or health information, as well as their attitudes toward various organizations related to food business, including food industry, US government, media, and farmers.

Statistical Analysis

All data were analyzed using SPSS (version 20; IBM, Chicago, Illinois) and Microsoft Excel (2010, version 14). Categorical variables were summarized as frequency distributions and percentages. Continuous variables were presented as mean and standard deviations. Comparisons were made between income groups, where specified (Lo150 vs Lo250), using the z test statistic to test the equality of independent proportions and independent t test for mean values. Within response categories across informational content statements, answers were scored and compared by t test analysis. Survey distribution (online vs in-person) was tested revealing no significant impact on study results (P > .05); thus, data were combined for all analyses. All tests were evaluated for statistical significance based on P ≤ .05.

RESULTS

Demographics

As shown in Table 1, the income groups were not different on measures of age, gender distribution, number in the household, or number of children at home but did differ significantly on race/ethnicity, body mass index (calculated from self-reported height and weight), education, and marital and employment statuses (P < .05). A greater percentage of African American people were in the Lo150 group (P < .05), and, in general, the Lo150 group completed fewer years of school (P < .05) and had a higher body mass index (P < .05; Table 1). The Lo250 group was more likely to be employed than the Lo150 group (P < .05). The difference in income between the 2 groups was approximately $900 to $1330 per month.

Purchasing Characteristics and Behaviors

Table 2 represents the findings from questions designed to assess purchasing characteristics and behaviors, which were presented in an open-ended answer format or using 5-point Likert scaling. Examples of a few of the questions were as follows: “Where do you normally do your grocery shopping?”, followed by a list of possible shopping venues; “How often do you purchase fresh fruits and vegetables?”, followed by frequency selections ranging from more than twice per week to less than once per month; “Are fresh fruits and vegetables available where you do your grocery shopping?”, followed by a 5-point scale from “always” to “never”; and “Are organic fresh fruits and vegetables available where you do your grocery shopping?”, followed by a 5-point scale from “always” to “never.” Other questions were related to transportation to shopping locations, how often organic produce was purchased, and, if organic produce was not purchased, “why not?”.

We found that the 2 income groups (Lo150 and Lo250) differed on purchase frequency, organic purchases, store type, and modes of transportation. In general, more people in the Lo250 group drove a car to shop (vs bus), shopped more than once per week (P < .05), and reported shopping at specialty stores (including health food store and/or organic food store), although the percentages were relatively low (<11%) for both income levels (P < .05). More people in the Lo250 group reported purchasing FV weekly, and, whereas organically grown FV purchases were low for both groups (≤17% indicated purchasing organic FV), more than 50% fewer Lo150 participants reported purchasing organic FV. Correspondingly, almost twice as many Lo150 versus Lo250 participants reported that they “do not buy” organic FV. Both groups (~80%) indicated that fresh FV are available where they do their grocery shopping, and 44% of these people reported having organic produce available.

Factors Influencing FV Purchasing in General

As indicated previously, fresh produce was generally available, including organic options. When asking what factors influence their overall FV purchasing decisions (in an open-ended question), 39% reported freshness/shelf life, 35% reported cost, 30% indicated taste/preferences, and 29% reported nutrition/health as the top factors in their decision making. Interestingly, cost was number 3 for the Lo150 group but was the number 1 reason for the Lo250 group. The same question was asked again regarding the factors that influence their overall FV purchasing decisions in a multiple-choice presentation. In this presentation, 40% selected “cost” as the most important factor influencing their FV purchasing decisions, whereas 21% selected nutritional value, 19% selected safety from contamination or foodborne illnesses, and 10% selected free from chemical pesticide residues. Other selections in declining order were as follows: whether it is organic or grown locally or whether it is grown in the United States or imported. Responses did not differ between income groups except for the selection of “free from chemical pesticide residues”; in which case, 15% of the Lo250 group selected “free from chemical pesticide residues” as the most important factor influencing their purchasing decision compared with 8% in the Lo150 group, P < .05. When subjects were asked whether they were having difficulty obtaining fresh FV, a greater percentage of participants in the Lo150 group indicated having difficulties obtaining fresh FV compared with the Lo250 group, and financial barrier(s) was the reason most often reported, followed by availability, disability, and lack of transportation.

Factors Influencing Organic FV Purchases

Fewer than half of the survey respondents indicated that organic FV were available where they do their shopping. Given that shoppers told us that nutrition/health, safety/pesticide, and taste were important factors influencing their (general) FV purchases, we were interested in understanding more about participants' perceptions and awareness of issues about conventionally versus organically grown produce, including their top reasons for purchasing or not purchasing organically grown FV.

To first understand the awareness of terms and potential associations with terms, we asked participants, “When you hear that a fresh fruit or vegetable is grown ‘conventionally,’ what does that mean to you? Please describe” or “When you hear that a fresh fruit or vegetable is grown ‘organically,’ what does that mean to you? Please describe.” Thereafter, we asked, “If you purchase organic fresh fruits and vegetables, what is the main reason you buy them?” and “If you do not purchase organic fresh fruits and vegetables, what is the main reason you don't buy them?” Answers were open ended, and key words/phrases were coded for quantification and analysis. Participants may have indicated more than 1 answer.

Thirty-four percent of the survey respondents associated conventionally grown FV with the “use of pesticides/fertilizers/chemicals,” and 56% associated organic farming practices with “free of pesticides/fertilizers/chemicals.” Not surprisingly, some (18%) had never heard the term conventionally grown, whereas others associated the term with “grown on farm/traditional farming method” or “mass production method.” In response to the term organic, participants indicated “more nutritious/healthier” and “natural,” and 10% never heard the term organically grown. The top reasons for purchasing organically grown FV were nutrition/health, pesticide free, reduced cost/sale, and taste, whereas the top reason not to purchase organically grown FV was cost. Factors that influenced organic FV purchasing are shown in the Figure. The ranking of responses was similar in both the Lo150 and Lo250 groups. When asked about the promotions of organic produce, 61% of the participants indicated that they felt media encourages them to purchase organic foods. Participants also indicated that they would purchase organic more often if more affordable and available.

Reactions to Communications About Organically and Conventionally Grown FV

Because education and communications are vital to help consumers choose healthful food options for their families, we examined how common educational/informational content about conventionally and organically grown FV may impact their purchasing intent of FV (in general). Ideally, we want publically communicated information about FV to motivate more people to purchase FV and to steer away from language that results in less people wanting to purchase FV. Therefore, we asked participants to “Please read the following statements. For each statement, please indicate how likely you would be to purchase fresh fruits and vegetables regardless if it is conventionally or organically grown.” Statements were provided one at a time, each followed by the statement “Based on this information, how likely are you to purchase fresh fruits and vegetables in general?” and a 5-point Likert scale of responses from which participants responded “much more likely,” “somewhat more likely,” “no difference,” “somewhat less likely,” or “much less likely” to purchase fresh FV. Seven statements of informational content were presented each separately and with the same response options as noted previously (Table 3). Because of the low number of responses at the extremes of scales, the Likert scale was pooled to represent “more likely,” “less likely,” or “no difference” for the final analysis and presentation of results.

Among the informational statements presented about organically and conventionally grown FV, the statement pertaining to “organic fresh produce carries lower pesticides than conventional” (Table 3, question 1) elicited the greatest number of participants to choose “more likely” to purchase any type of FV. The response was significantly higher compared with responses for other statements (62% vs 51%–57%, P < .05) except for the statement: “research studies indicate pesticides in both conventional and organic fresh fruits and vegetables are low and safe” (Table 3, question 2), which elicited 59% of the participants choosing “more likely” to purchase FV.

The statement that was most neutral as indicated by the highest percentage of respondents choosing “no difference” in their likelihood to purchase FV was the statement focused on health benefits: “no evidence to prove better nutritional benefits with organic vs conventional fruits and vegetables” (42% vs 31%–37%, P < .05; Table 3, question 3). However, certain statements resulted in a shift to “less likely” to purchase any FV, which is of greatest concern. The statement specifying “12 fresh fruits and vegetables believed to have the highest pesticide levels” (Table 3, question 4) elicited the greatest number of people to choose “less likely” to purchase any type of FV. The response frequency was significantly different at 15% versus 6% to 10% for other statements (P < .05). The statement pertaining to “certification by USDA to be an organic farmer and the regulations are strictly enforced” elicited the second highest number of “less likely” responses (10% of the participants) (Table 3, question 6).

Credible Sources of FV Information Identified by Shoppers

Shoppers (>31%) told us that they trust dietitians/nutritionist the most for health and safety information about fresh FV, followed in descending order by scientists (16% said that they trust scientist the most), physicians (14%), environmental groups (12%), media (10%), and then government agencies (9%). Attitudes toward the food and agricultural industry–associated entities suggested general skepticism with regard to the safety of the US government's approved pesticides and the intentions of the food industry. In contrast, more than half of the participants indicated that they agreed farmers have consumers' best interest in mind. The Lo250 group tended to be more skeptical of the food industry and government compared with the Lo150 group.

DISCUSSION

Low-income individuals constitute a financially vulnerable group of people with challenges to meet many daily household needs, including consuming a healthy diet. When incomes drop and family budgets shrink, food choices shift toward cheaper more energy-dense foods.²⁴ Fruits and vegetables are one of the first items shown to drop with declining incomes. In addition to budget constraints and perceived high costs of FV, lack of knowledge and confusion about healthy foods, lack of availability and access, and poor produce quality are other factors influencing FV purchases and consumption.^5,7–11 Consistent with these previous studies, this study found that food quality/freshness, cost, and perceived nutritional/health values are important drivers of FV purchases in low-income groups. In addition, however, we found that even within low-income categories, these drivers can differ. Of particular interest was the finding that cost was a greater concern among the Lo250 group than the Lo150 group when purchasing FV.

FV Cost Concerns in “Higher” Low-Income Shoppers

Unexpectedly, we learned that people in the Lo250 group had more FV cost concerns than people in the Lo150 group. We expected that the Lo250 group would have more expendable income per month, which may relieve FV cost concerns. However, this was not the case and may be because, with modest increases in income, the sense of increased choice presents new challenges in healthy food decision making. A perceived conflict between cost and the need to buy “pesticide free” or “organic” within the Lo250 group was suggested by responses to two separate questions about the “the most important factors you are thinking about when ‘deciding to purchase’ or ‘selecting’ fresh fruits and vegetables to purchase.” Significantly more people in the Lo250 than the Lo150 group provided responses specific to “pesticide usage” or “free of chemical pesticides” as important factors they are thinking about when deciding to purchase or selecting fresh FV to purchase. In addition, more participants in the Lo250 group showed distrust in the food industry, government, and farmers and responded that they try to buy organic when they can. However, adding the challenge of limited access and availability of organic produce in low-income communities could discourage purchase of any FV when organic is not available. Taken together, a possible net effect is decreased FV purchases and intake. These findings suggest a need for additional research to better understand the interaction of income level, including small incremental changes in income, and organic and nonorganic FV messaging and education. Clearly, a strong message is heard regarding pesticide residues and FV among low-income shoppers. The extent to which this information impacts FV intake and public health efforts to increase FV intake is not clear and warrants follow-up.

Communicating About Organically and Conventionally Grown FV

Communication through various media outlets conveys messages that organic FV are healthier and safer than nonorganic, conventionally grown FV. Data collected through this survey found that 61% of the participants agreed that they felt media encourages them to purchase organic foods. Whether this advice is helpful or hurtful in motivating FV consumption depends on many factors, including what and how information is conveyed. In our exploratory analysis of likelihood to purchase any type of FV after reading informational content from government sites, research studies, or advocacy groups, we found that most participants (~50%-60% depending on information read) were “more likely” to purchase FV after reading the statements; however, the other half responded no difference in FV purchases or were “less likely” to purchase FV the next time they go shopping. Important was the identification of what type of message or information tended to shift responses from “more likely” to purchase FV to alternative choices of “no difference” or “less likely” to purchase FV. Two of the seven statements were identified as shifting group responses. When shoppers read the statement about “…No evidence to prove better nutritional benefits with organic vs conventional fruits and vegetables…,” fewer shoppers chose “more likely,” and more shoppers chose “no difference” in their likelihood to purchase FV, suggesting that the message was generally neutral. Instructively, this tells us that we should find better ways to communicate the nutritional value of FV in the context of organic and conventional growing practices to motivate increased (vs maintaining usual) likelihood of purchasing FV.

More concerning are messages or informational statements that demotivate shoppers to purchase FV. The statement listing and naming types of FV with the highest pesticides levels “…12 fresh fruits and vegetables believed to have the highest pesticide levels…” resulted in more shoppers choosing “less likely” to purchase FV. Because 4 other statements providing information about pesticides or food contaminants did not result in shifted responses, these results reiterate the importance of how information is communicated. People’s reactions to informational content, and, in this case, unfavorable reactions were associated with listing by name FV with pesticide residues.

Negative and positive framing of messages about organic food on organic purchasing likelihood have been reported previously showing differential responses to messages in a mixed-income population ranging from $12 000 to $135 000 annually.²⁰ Cucchiara et al²⁵ (2015) also found differential responses of purchase intention to negatively and positively framed messages regarding organic seafood. Different responses to messages could be a result of difference in previous subjective knowledge, trust in food safety, educational level, and risk perception.^26,27 This study sheds light on potential conflicts in factors that impact FV purchasing intent in an exclusively low-income population and, in particular, shows how this shifts with a modest increase in income. Given the public health importance of increasing FV consumption across all demographics, understanding how communication around a highly debated topic, such as organic and conventional FV, influences intake is of utmost importance.

CONCLUSIONS AND RECOMMENDATIONS

This study revealed the complexity of influences on FV purchasing among low-income individuals. The research highlights the need to better understand the interaction between (low) income, including small incremental changes in income level, organic and nonorganic FV messaging and education, and FV intake. It is clear that low-income shoppers are hearing messages about pesticide residues and FV. It is also clear that the content and how the information is presented could negatively impact overall FV purchasing and intake in low-income populations. Hearing that most shoppers in this survey trust dietitians/nutritionist, scientists, and physicians for health and safety information about fresh FV presents an important opportunity for these professionals working in low-income populations to educate shoppers about organically and conventionally grown produce. Additionally, these professionals have the opportunity to teach shoppers about best practices in handling all FV to minimize their confusion and safety concerns and enjoy FV more often. Acknowledging that media also play a significant role in communications suggests that continued professional interactions with media to educate and help them translate science about FV growing practices, real versus perceived safety issues, and benefits of FV will be of critical importance to ensure consumers are getting accurate and actionable information relevant at all income levels. Overall, the present research underscores the need for further research to better understand perceptions of FV issues, particularly within low-income groups where the barriers to intake are greater and more complex, and, moreover, to use this research to inform and develop effective communication strategies consistent with promoting and achieving public health FV goals.