Citation: Leng, K.H.; Yaroch, A.L.; Nugent, N.B.; Stotz, S.A.; Krieger, J. How Does the Gus Schumacher Nutrition Incentive Program Work? A Theory of Change. Nutrients 2022, 14, 2018. https://doi.org/10.3390/ nu14102018 Academic Editors: Angela Odoms-Young and Tamara Dubowitz Received: 18 March 2022 Accepted: 5 May 2022 Published: 11 May 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). nutrients Article How Does the Gus Schumacher Nutrition Incentive Program Work? A Theory of Change Kirsten H. Leng 1, *, Amy L. Yaroch 2 , Nadine Budd Nugent 2 , Sarah A. Stotz 3 and James Krieger 1,4 1 Healthy Food America, Seattle, WA 98122, USA; jkrieger@hfamerica.org 2 Gretchen Swanson Center for Nutrition, Omaha, NE 68154, USA; ayaroch@centerfornutrition.org (A.L.Y.); dnugent@centerfornutrition.org (N.B.N.) 3 Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; sarah.stotz@cuanschutz.edu 4 School of Public Health, University of Washington, Seattle, WA 98195, USA * Correspondence: kleng@hfamerica.org; Tel.: +1-206-412-0997 Abstract: Increased fruit and vegetable (FV) intake is associated with decreased risk of nutrition- related chronic diseases. Sociodemographic disparities in FV intake indicate the need for strategies that promote equitable access to FVs. The United States Department of Agriculture’s Gus Schu- macher Nutrition Incentive Program (GusNIP) supports state and local programs that offer nutrition incentives (NIs) that subsidize purchase of FVs for people participating in the Supplemental Nu- trition Assistance Program (SNAP). While a growing body of research indicates NIs are effective, the pathways through which GusNIP achieves its results have not been adequately described. We used an equity-focused, participatory process to develop a retrospective Theory of Change (TOC) to address this gap. We reviewed key program documents; conducted a targeted NI literature review; and engaged GusNIP partners, practitioners, and participants through interviews, workshops, and focus groups in TOC development. The resulting TOC describes how GusNIP achieves its long-term outcomes of increased participant FV purchases and intake and food security and community eco- nomic benefits. GusNIP provides NIs and promotes their use, helps local food retailers develop the capacity to sell FVs and accept NIs in accessible and welcoming venues, and supports local farmers to supply FVs to food retailers. The TOC is a framework for understanding how GusNIP works and a tool for improving and expanding the program. Keywords: nutrition incentives; fruit and vegetables access/intake; health equity; food security; low income; food systems; theory of change; Supplemental Nutrition Assistance Program (SNAP); Gus Schumacher Nutrition Incentive Program (GusNIP) 1. Introduction Fruit and vegetable (FV) intake is associated with decreased risk of chronic dis- eases [1,2]. Yet, Americans generally do not eat enough FVs to meet federal recommenda- tions [3]. Fruits and vegetables (FVs) are often more expensive than non-perishable, less healthful ‘convenience’ foods [4]. Many households with low incomes cannot afford to purchase necessary quantities and varieties of FVs needed to meet dietary guidelines [4–7]. The accessibility, availability, and affordability of FVs are influenced by the structural environment of economically distressed communities and shaped by historical and political contexts [8]. To promote increased FV intake among people with low incomes, Congress established the Gus Schumacher Nutrition Incentive Program (GusNIP) in 2018 [9–11], building on the preceding Food Insecurity Nutrition Incentive (FINI) program [12]. GusNIP is authorized to spend USD 250 million over five years and is administered by the United States Department of Agriculture (USDA). The largest component of GusNIP is a competitive grant program that funds state and local non-profit organizations to provide financial nutrition incentives Nutrients 2022, 14, 2018. https://doi.org/10.3390/nu14102018 https://www.mdpi.com/journal/nutrients