The sampling frame for the readiness assessment included all federally qualified health centers (FQHCs) in South Carolina (N = 20). These centers represent 163 practice sites. The Executive Director of each FQHC was initially contacted to complete a brief survey to determine interest in establishing a farmers’ market at one of their practice sites. Six FQHCs (31.6%) indicated interest in establishing a farmers’ market at a practice site(s). These six FQHCs received a second survey to identify the specific practice sites within their network that might be interested in the farmers’ market intervention. Five FQHCs completed the second survey and identified 15 potential practice sites for the intervention. Onsite key informant group interviews were conducted at four FQHCs; one was excluded because it was located more than 100 miles from the university where the research team was based. Group interviews included two to five key informants such as the Chief Executive Officer, Medical Director, Nursing Director, and Compliance Officer.

Descriptive statistics of the contextual data were calculated. Qualitative data were analyzed inductively and iteratively by an interdisciplinary team of four researchers to identify themes. Each reviewer presented coded data to the research team; areas of agreement and divergence in coding patterns were discussed and used to refine the codebook. Themes were accepted based on group consensus regarding salience in the data sources.

Capacity was identified as a key indicator of community health center readiness. We defined capacity as the ability to mobilize health center and community resources to implement and sustain the intervention. Indicators of capacity included two dimensions: institutional support and a previous history of programming to increase access to healthy foods or improve diet.

Institutional support included clinic and community leaders who could serve as organizers for the intervention. Clinic leadership was evidenced by key informants when they identified staff on-site who could become champions for the farmers’ market. One site had an employee wellness program that would also provide staff support for this type of intervention. Community leadership was illuminated when key informants described access to community resources including local churches, colleges and universities, and elected officials who could not only support the cause but also provide assistance during the planning and implementation stages. Other indicators of capacity included prior relationships with local non-profit organizations and governmental agencies that could assist in the process such as the Department of Social Services, Department of Health and Environmental Control, Head Start, Council on Aging, Migrant Health, and Association of Pastors. Respondents indicated that previous partnerships with these organizations would enable the community health centers to build on ties that were already in place. In addition, the implementation of the farmers’ market would allow the centers to forge new relationships that had not previously been attempted.

The second dimension of capacity was a previous history of programming to increase access to healthy foods or improve diet. Prior programming included cooking classes, food and nutrition education, community gardening, and a financial incentive program for produce purchased at a local farm stand. Although none of these programs were currently in operation, experiences with them provided insights for future environmental intervention efforts. For example, stakeholders at one site described barriers that emerged during a previous food access program such as inconvenient time of the program and lack of support to sustain the efforts.

Social capital was identified as a key indicator of readiness. We defined social capital as the ties and connections available that may be leveraged to mobilize environmental interventions at the community health center [25]. Indicators of social capital included three dimensions: partnerships and collaborations, collective efficacy, and public image.

The degree to which the community health center was connected to and in partnership with other community organizations was one aspect of social capital. This was evidenced through formal interactions such as staff involvement with local boards and civic associations such as Rotary Club, Kiwanis, and faith-based organizations. Other indicators of connectedness and partnership with the broader community included the provision of health fairs in community venues and regular distribution of newsletters to partners. Additionally, connections to key stakeholders such as government leaders (e.g., mayor, city council) and local community foundations (e.g., United Way) were indicators of connectedness. The second dimension of social capital was the level of connection among stakeholders in the broader community in which the health center resided and a belief that these connections could be activated for change (i.e., high collective efficacy). In essence, was the health center situated within a “tight knit” and active community? This was evidenced by the identification of strong and active neighborhood associations, faith-based organizations, schools, and universities near the health center. Key informants reported that some of these groups had worked on farmers’ markets in the past or were currently running nearby markets, and thus provided experiential wisdom to future farmers’ market efforts. The third dimension of social capital was the self-reported public image of the health center. Overall, the community health centers perceived that they were well-received by the community but noted an interest in improving their public image. One site, for instance, indicated that they wanted to move from being solely a “resource” in the community to an “asset.” Another indicator of public image was the types of patients at the community health center site. FQHCs are primary health care facilities that can be used by any type of patient, though they tend to be viewed as primarily serving uninsured and underinsured populations. Stakeholders often noted during the site visits if they provided care to community leaders. For example, one site was very proud that the president of a local university was one of their patients and also a public advocate for the community health center. The presence of community leaders as patients was perceived to be a marker of status in the community. Furthermore, each site indicated that they wanted to increase the diversity of their patient population, and they viewed the farmers’ market as one tool for recruitment.

An additional dimension of readiness that emerged was the centers’ awareness of health-related problems, needs, and solutions in their communities. Awareness themes were related to: an ecological perspective of community health problems and the need for healthy food availability; a community-informed recognition of these health problems and needs; existing barriers to accessing and eating healthy foods; and the vision that the farmers’ market will serve as the solution to community health problems.

First, staff at the community health centers had an awareness of community needs based on an ecological perspective to health. That is, key informants recognized that the health problems they were witnessing at the community health center were affecting a large proportion of the community and needed to be resolved at the community level, not merely an individual level. Key informants discussed problems such as obesity, diabetes, and other diet-related conditions and they stressed the importance of increasing the health and quality of life of the community as a whole. Specific communities of interest included the clinic, faith-based, neighborhoods, and business. Key informants noted clinic patients’ needs for affordable and healthy foods as a solution to health problems, and they recognized the importance of communitywide involvement in efforts to improve health.

Second, it was evident that key informants’ knowledge and awareness of community health issues were based on their own life experiences from being part of the community. From direct involvement in and frequent interaction with the community, center staff and stakeholders were familiar with health concerns such as poor eating habits, unhealthy cooking styles, and limited access to fresh produce. Their descriptions of previous experiences with community health promotion programs also demonstrated this informed awareness. Third, health centers were very aware of community barriers to accessing and eating healthy foods such as the high cost of fresh produce and healthy foods, long distance to stores selling fresh produce, lack of transportation, and inconvenient hours of store operation. Key informants also perceived that health center patients had limited understanding about the importance of healthy eating and the relationship between diet and health.

Finally, all centers anticipated that starting a farmers’ market at their site was one solution to overcoming these barriers and meeting the health needs of the community. When asked to describe their vision for an on-site farmers’ market, key informants unanimously agreed that it would provide the community with convenient, affordable, and healthy foods; provide preventive care to patients and the broader community; allow for better health care provision; create an opportunity for point-of-purchase health education; provide a space for social interaction and community connectedness; and serve as a catalyst for recruiting more patients to the health center. In short, sites perceived the farmers’ markets to be a mutually beneficial approach to improving the health of the community and supporting the mission of the health center.

Logistical factors emerged as particularly important and not easily modifiable factors related to readiness for establishing a farmers’ market at a health center. Logistical factors included elements of physical location, patient volume, and access to local farms and farmers (see Table 1). It was imperative that the sites had outdoor space available with access to electricity, space for farm vendors, parking for customers, and restrooms. All of the sites had outdoor space available for the farmers’ market; however, three of the sites had limitations related to access to the other resources. For instance, one site did not have access to a restroom without interrupting patient care; a portable restroom would have been needed at this site. It was also important that the health center was located in a high traffic area to ensure adequate customer flow. One of the sites was located on a main highway with both a high school and a college within miles, a low-income apartment complex adjacent to the health center, and a bus stop near the site. Another health center was located on a bus line in a community inclusive of two historically black colleges and near at least seven predominantly African-American churches. The two most rural sites indicated that inadequate public transportation was a logistical barrier for their patient populations. For instance, key informants at one of these sites indicated that the bus only came by the health center twice per day—in the early morning and late afternoon. Patient volume was another logistical factor considered. The community health centers reported that they provided care for between 100 and 300 patients daily and had staff sizes ranging from 15 to 100. Based on reports from a state-wide electronic medical record system for the health centers, we learned that about two-thirds of the patients at each site had a chronic health condition that required regular visits to the health centers (see Table 1).

We also reviewed the US Agricultural Census and Local Harvest website to examine farming trends near each site because we needed farmers to fulfill the demand created by the emergent farmers’ market. Finally, the distances between the health centers and the university were considered because we had limited funding for travel costs for the research team. The health centers were between five and 80 miles away from the university

Finally, sustainability factors emerged as indicators of readiness. Sustainability factors encompassed understanding of the demands of the intervention, broad support for the project, and ownership of the project that would contribute to the continuation of the farmers’ market. Key informants indicated varying degrees of awareness of the demands associated with operating a farmers’ market at the community health center. One site was unclear about the demands whereas the others were aware of the costs and commitments related to this type of environmental intervention. The most salient demands were related to the time needed to develop and execute a farmers’ market and the costs associated with this type of intervention. One site expressed strong concerns about the time and cost demands in a setting that was already constrained; key informants at this site inquired about the need for hiring a farmers’ market manager to assist with this type of intervention. A few key informants expressed the need for developing a business plan to ensure that the farmers’ market was economically sustainable.

Another indicator of sustainability was the level of support or buy-in for the farmers’ market by staff, patients, and the broader community. Staff support was revealed, in part, by the key informants in attendance at the on-site interviews. Only one site included their CEO in the interview, though the CEO of the other sites expressed regrets for not attending and indicated that they were supportive of the farmers’ market intervention. Staff support also was evident when key informants defined how the farmers’ market intervention would support the mission of the health center. All sites indicated that the farmers’ market would advance their mission to provide quality, comprehensive health care by increasing access to healthy foods; the market was also identified as a method for recruiting new patients to the clinic, which would further their mission. Two sites provided a much broader vision of the farmers’ market intervention; they envisioned the markets to be the first stage in a series of interventions, such as grocery stores and urban agriculture programs, to increase food access and economic opportunity for their patient population and the broader community. Key informants expressed the need for engaging patients and the broader community to ensure market sustainability. One site indicated that they would need to actively engage a neighborhood association and nearby churches to facilitate success. Finally, the level of ownership of the farmers’ market by key stakeholders was identified as an important element of sustainability. Two sites reported that they had recently engaged in a community garden and farmers’ market intervention program but had very little ownership of these interventions. Given their limited ownership, the community garden project ended once funding ended and the future of the farmers’ market project was unclear.