Training, Coaching and Marketing Program for Vegetable and Fruit Vendors in Markets to Improve Food Safety Practices and Vegetable and Fruit Intake Among Women 20-49 yr Old in Quezon City, Philippines (VBS4HD)

The study is a community-based two-arm clustered randomized control trial to assess the effect of a 'training, coaching and marketing' program for small-scale fruit and vegetable vendors operating in urban private markets on the vendors' food hygiene practices and fruit and vegetable intake on adult women 20-49 yrs old from client-households: the VBS-4HD trial protocol.

Over the past 10 years Philippines has experienced a steady increase in overweight and obesity rates across practically all population groups. And while the trend is seen all across the country, it is particularly pronounced in urban settings where it has been estimated that 15% of school children and adolescents and close to one in every three adults are currently overweight or obese. These trends are not expected to reverse in the near future. Philippines ranks also among the top five countries in South and Southeast Asia in number of deaths due to non-communicable diseases attributable to diets. These overnutrition trends co-exist with persistent high levels of stunting and wasting and micronutrient undernutrition. In Southeast Asia, Philippines has the third worst incidence of severe and moderate food insecurity (44% of the population) among countries in Southeast Asia and 48% of the population cannot afford a healthy diet.

As part of efforts to understand these negative nutrition outcomes, multiple studies and assessments reveal that Filipino diets are low in vegetable and fruits, and high in sugary, fatty and salty products, with these diets being more commonplace in urban settings. Three in every four children aged 13-15 eat less than three portions of vegetables per day (from the recommended 5 portions), while about one third (38%) drink at least one soft drink per day. Similarly, while three quarters of women in reproductive age consume at least one portion of vegetables per day, the daily intake remains below recommendations. These diets are far from the current WHO recommendations for a healthy diet. Despite efforts by the national and local governments to work toward healthier food environments and healthier food choices, Filipino diets and nutritional outcomes seem to be worsening.

Reversing these trends requires identifying and addressing key drivers of unhealthy diets. The literature indicates that Filipinos diets in urban settings respond primarily to the following drivers:

• Demand for convenience food. Urban living involves increased demand on residents' time, through commuting to and from work, juggling income-earning and domestic work, especially for women, and often the need to work multiple jobs. This leaves less time for food preparation and increasing demand for quick and easy 'fast-food'.
• Supply and aggressive promotion of convenience food. Urbanization has created a marketing opportunity for major national and international fast-food companies. This trend has been particularly marked in the Philippines, where the quick service restaurants market value is expected to double between 2018 and 2026, with corresponding growth in promotion of these foods. In 2023, fast food establishments generated over seven billion dollars in revenue, often targeting young and adolescents.
• Unsuitable food system. The agrifood sector is failing to produce and deliver in a timely way enough, high-quality and affordable foods to cities, making fresh foods harder to access than fast, unhealthy foods.
• Cultural perceptions about foods. In Filipino culture vegetables are considered a 'side dish' not necessary to complete a main meal. Fruits are also not considered a standalone meal and are most commonly consumed in small quantities as desert. This means that a full meal is often lacking vegetables and fruits.
• Limited awareness of nutritional recommendations. Studies suggest that educated young adults in the Philippines have a low to moderate knowledge about nutrition and food handlers in households have limited awareness of the food dietary guidelines .
• Food price (affordability). In 2022, 55.6% of the population in the Philippines could not afford a healthy diet, estimated to cost US$4.10 per person/day . Although affordability is higher in urban compared to rural areas, price remains an important driver of food choices. Fruits and vegetables though remain an affordable food product and yet consumed in relatively low amounts. For example, fish can cost 3-4 times the price of fruits and vegetables, and both food groups are consumed in the same amount. Hence, affordability may be a less relevant driver of food choices compared to tastes and customs.

In an attempt to address the unhealthy diets and worsening nutrition trends, multiple strategies have been launched in the Philippines over the past years. "Kadiwa" is a Department of Agriculture marketing program to connect farmers to consumers through Kadiwa Centers, or farmers markets. In Quezon City (QC), the biggest city in Metro Manila, farmers are also facilitated access to selling spaces in local markets. Despite these efforts and local policy requirements to increase availability of fresh vegetables in communities, the national agriculture agenda continues to preferentially promote the supply of high-volume staple commodities such as rice and cereals, rather than fresh vegetables and fruits.

On the demand side, the Food and Nutrition Research Institute -DOST (FNRI-DOST) launched in 2016 the 'Pinggang Pinoy' (or "Filipino plate"), a visual food guide to help Filipinos adopt healthy eating habits by showing recommended proportions of food groups per meal. To promote the Pinggang Pinoy plate, FNRI-DOST has encouraged food companies to adopt it in their menus and has collaborated with the National Nutrition Council to promote it at national level through new ordinances. However, progress on promotion and adoption of healthier diets is slow and the growing trend of overweight and obesity continues. New approaches are needed to reach the population with good nutrition messaging.

The above mentioned drivers influencing the urban food environment exist alongside what is still the dominant food supply chain: wet markets, street selling and kiosks which continue to be the primary sources of fresh vegetables and animal products, dry and prepared foods, especially for the poor. This 'informal' food sector accounts for around 60% of domestic food supplies in the Philippines and is an important source of employment, especially for women. Yet these markets have been extensively under invested in and neglected in national and local food strategies. Recognizing their critical role in the city's food system, Quezon city established in 2024, in partnership with CGIAR researchers, the "Vendor Business School' (VBS) to enhance entrepreneurial skills of informal market traders and hawkers. The VBS is a capacity strengthening program that provides group training session and individual coaching over a six-months period in business skills, food safety and customer relations. In 2024 the VBS onboarded 120 food vendors (72% women) in public/private markets and hawker sites. The pilot of the program revealed high satisfaction of vendors with the program, that vendors expanded their businesses and in general increased their revenues. In light of this success, the QC government has just approved a city ordinance that institutionalizes the VBS. Because informal food outlets are such an important part of the urban food environment, they have an exceptional potential to influence food choices and diets. We argue that the informal urban food sector could offer local governments a complementary strategy: a powerful tool to stimulate increased consumption of nutritious foods and healthier diets. The VBS could be leveraged for its ability to improve urban diets.

As has been witnessed in the massive growth of the fast-food sector, food marketing is a very powerful strategy to influence consumer choices, widely use in Asia to promote consumption of unhealthy foods. The potential of marketing as a tool to promote nutritious foods is understudied. Most research on interventions to affect food choices and, overall, the healthiness of diets, have focused on three main areas: (i) improving access to high quality foods such as fruits and vegetables such as home gardens or school meals, (i) improving knowledge and awareness of the healthiness of diets, through different educational models, or (iii) using nudges to influence consumer behavior. This last category has been increasingly studies over the past decade and includes different approaches: changes to the physical environment (or "position nudges"), changes to the default policy (labeling), simplification and framing of info (including marketing), and changes to social norms (mass campaigns). The scientific evidence on the effectiveness of nudge-based approaches based on mass campaigns and marketing remains very limited but has shown promise in widely different set of settings and it seems their effect could be stronger among individuals of low-socioeconomic status. Yet, the focus of such research has been on the use of these strategies at country or community level and in modern retail context. Moreover, the cost of traditional mass and commercial marketing may make it prohibitive and less relevant in low-resource settings in most low- and middle-income countries. The design of alternative, low-cost market-driven marketing approaches could represent a more cost-effective approach to marketing-based nudging in such settings. However, the scientific evidence base on this is largely lacking.

A recent intervention conducted in Kenya worked with the vast network of marginalized informal dairy vendors to transform them into advocates and vehicles for promotion of milk consumption. A capacity development program for the dairy vendors coupled with a milk marketing campaign led to 40ml increase in their daily intake of milk through consumer-vendor interactions and exposure to the marketing campaign. Such a strategy could be effective in other contexts and for different food types, but evidence is as yet limited.

This study seeks to assess the ability of a 'training, coaching and marketing program' (Vendor business school for healthy diets; VBS-4HD) offered to small-scale fruit and vegetable vendors operating in private markets in a city in the Philippines to increase uptake of good food handling practices and monthly business profits of participating vendors, as well as increase fruit and vegetable intake of adult women 20-49yrs old living in consumer-households buying vegetables from the participating vendors. Effect will be measured against the outcomes in a group not exposed to the program, which represents the current status in markets.