Modelling enablers and barriers to improve uptake of a fruit and vegetable voucher scheme (the fresh street community) in England: a TISM-MICMAC approach

Improving equitable access to fresh fruit and vegetables (FV) remains a critical public health priority in the UK, particularly in low-income communities where affordability, accessibility, and social barriers limit healthy food choices. The Fresh Street Community scheme, a place-based FV voucher initiative in England, aims to enhance dietary equity by enabling households to purchase fresh produce from local community centres. Building on prior feasibility research, this study applies a systems-modelling approach to explore how multiple enablers and barriers interact to influence scheme uptake and sustainability. Using Total Interpretive Structural Modelling (TISM) combined with MICMAC analysis, we engaged research team members, local household participants, and community food researchers across two contrasting sites in England – a coastal and an urban community. Through participatory modelling, factors identified from previous qualitative work were hierarchically structured and classified according to their driving and dependency power to identify key leverage points for improving intervention design and implementation. The analysis revealed complex, multi-level interactions shaping scheme participation. Foundational structural drivers, such as convenient location, produce quality, and operational reliability, strongly influenced engagement. These interacted with social capital factors, including community relationships, peer advocacy, and local trust, which amplified awareness and reduced stigma. Resource adequacy emerged as a pivotal linkage factor, determining the stability and reach of the intervention. Effective and sustainable FV voucher schemes require coordinated, multi-level strategies that strengthen physical and economic access, mobilise community networks, and secure sufficient resources. This systems-modelling approach offers policymakers and future researchers a practical framework to address persistent challenges in food access and health equity, supporting the development of more resilient, impactful food intervention schemes.