Market to Mouth – Coming Full CircleWhat do people do with foods purchased at a health center-based farmers’ market?

Darcy A. Freedman, MPH, PhDAssociate Professor, Department of Epidemiology and Biostatistics, Social Work

Core Faculty, Prevention Research Center for Healthy NeighborhoodsCase Western Reserve University

Prevention Research Center for Health Neighborhoods SeminarMay 14, 2014

Agenda Rationale for integrating farmers’ markets/food access interventions

into health care delivery systems Formation of Right Choice Fresh Start Farmers’ Market Outcomes Related to Right Choice Fresh Start Farmers’ Market

Importance of Building Demand along with Supply Teamwork Activity (20 min) Discussion and Questions

1 in 3 National Health Interview Survey participants who were chronically ill reported they were unable to afford food, medications, or both.

Journal of Nutrition

Diabetes Care

Journal of Hypertension

Journal of Nutrition

Journal of Clinical Oncology

Hippocrates (~460BC-370BC)

Father of Western Medicine Medical Revolutionary

Natural causes of disease (e.g., environment, diet, living habits) vs. punishment from gods

Food as medicine philosophy

Store Type(33 stores)

Quality Composite Score

(mean)

Example

Convenience Stores (70%)

-0.74

Local Markets (24%)

-0.38

Supermarkets (6%)

6.5

Composite score = sum of scores for access to fresh fruit, fresh vegetables, lean meats, low-fat milk,tobacco products, alcohol. Chronbach’s alpha = .76

Source: Freedman & Bell, 2009

Example literature showing relationship between food environment and diet, chronic disease: Liese, Weis, Pluto, Smith, & Lawson, 2007; Moore & Diez Roux, 2006; Morland, Wing, Diez Roux, & Poole, 2002).

If you build it will they come? Columbia Food Fresh Market – closed after 1.5 years

<50% of residents in a food desert shop at newly developed store – United Kingdom (Wrigley, Warm, & Margetts, 2003)

People pass 1+ stores in their neighborhood to reach their primary store for food shopping (Liese et al., in press; Drewnowski et al., 2012)

Freedman, Blake, & Liese, 2013

Federally Qualified Health Center-based Farmers’ Market

FQHC Service Delivery Sites• South Carolina: 156• Ohio: 148• US: 7,621

Study Context Site selected (October 2010):

Family Health Centers, Inc., Orangeburg, SC Orangeburg County ranked 45 out of 46 for county health rankings**

South Carolina

Orangeburg County

Population, 2011* 4,679,230 91,910African American, 2011* 28.1% 62.3%Median household income, 2006-10* $43,939 $32,849Person below poverty level, 2006-10* 16.4% 25.8%Persons/square mile, 2010* 153.9 83.6

(micro-politan area)Adult obesity** 31% 40%Diabetes** 11% 15%

*US Census Bureau, **County Health Rankings

Engaging the Community

Memorandum of Agreement (10/2010)

Community Visioning Meeting (11/2010), N=50

Advisory Council (2/2011-ongoing), Hire Farmers’ Market Manager

Farmers’ Market opened June 2011; begins 4th season June 2014

Customer and Farmer Satisfaction Surveys (ongoing)

2012 D. Freedman transitioned out of active leadership

Freedman & Alia, 2013 -- manual

Outcomes of the RCFS

Individual-level Change in Fruit and Vegetable Consumption

Design: Longitudinal; no comparison group Sample: 45 diabetic patients at FQHC Intervention: FQHC-based farmers’ market +

financial incentive (up to $50) Outcome measure: F/V consumption measured with

NCI screener Results:

Dose-response relationship between improvement in F/V consumption and use of market

Improvers more likely to rely on financial incentive to purchase foods at market

Source: Freedman et al., 2013

Changes in Relationships between Patients and Providers

Design: Longitudinal; no comparison group Sample: 45 diabetic patients at FQHC Intervention: FQHC-based farmers’ market +

Produce Prescription ($1 and $5) By providers in clinic ($1) By health educator at diabetes education classes ($5)

Outcome measure: Patient-provider communication/relationship Provider role modeling at farmers’ market critical to

patient motivation for shopping

Source: Friedman et al., 2013

Social Relationships Supported through RCFS Design: Ethnographic observations Sample: 61 observations collected over 18 weeks Intervention: FQHC-based farmers’ market Outcome measure: social interactions between farmers,

consumers, and health care providers Results:

Importance of human and non-human actors (e.g., boiled peanuts, tables/chairs)

Interactions may mediate relationship between farmers’ market intervention and behavioral and health outcomes

Deal-making reduced price of produce, extended buying power Camaraderie provided incentive to return to market each week Recipe exchange gave informal opportunity to enhance food

preparation techniques

Source: Alia et al, 2014

Community-level Changes in Economic Opportunity for Farmers Design: Pre-post comparison Sample: 7,357 sales receipts for 20 weeks pre and 20 weeks

post intervention Intervention: Shop N Save Food Assistance Matching Incentive

$5 match for spending $5+ using food assistance at the farmers’ market

Outcome measure: Farmers’ market revenue, use of food assistance

Results: 336 people enrolled in Shop N Save program (Most were women,

African American, patients at the FQHC). All forms of food assistance used at market increased 10%-25%

of total sales. Overall market revenue increased from $14,285 to $15,720.

Source: Freedman et al., in press

Institutional-level Changes Sustained operation of farmers’ market at FQHC

2011, 2012, 2013, 2014… (visit in 2013)

Sustained implementation of Community Advisory Council Transition of leadership to community

Institutional-level Changes Sustained operation of farmers’ market at FQHC

2011, 2012, 2013, 2014… (visit in 2013)

Sustained implementation of Community Advisory Council Transition of leadership to community

Sustained commitment of staff to support implementation Health Education, Facilities Manager, Farmers’ Market Manager

Success in seeking funds to expand RCFS South Carolina Cancer Alliance 2012 Community Transformation Grant 2013 Farm Bureau 2013 Submitted—Community Food Project Grant (USDA) – 3rd try!

Societal-level Changes Documentary film to disseminate the story of RCFS

Community forums Film festivals Best Film Award, American Psychological Association

Society for Community Research and Action http://www.youtube.com/watch?v=viPtYFwzD6I

Proviso passed by SC General Assembly, June 2013 State-wide support for “double bucks” program--

$1.892 million RCFS is pilot implementation site

State Newspaper

Systems Change

"Systems change" is a shift in the way that a community makes decisions about policies, programs, and the allocation of its resources — and, ultimately, in the way it delivers services to its citizens.

Systems Change

Systems change may involve… Shifting system components and/or their sequence Shifting interactions between system components Altering the "whole" through shifts in underlying

choices, as well as… Shifting the manner in which the system provides

feedback to itself.

(Adapted from Foster-Fishman et al, Using a Systems Change Approach to Evaluate Comprehensive Community Change Initiatives)

Coming Full Circle with Systems Change Need to increase supply and demand for farmers’

markets

Market to Mouth StudyWhy do low-income consumers purchase and prepare foods from the RCFS farmers’ market?

Design: Cross-sectional interview study; recruitment on Friday for interview the following Tuesday-Thursday

Sample: 121 customers recruited from the RCFS market (65% response rate)

Results: 88% of sample had some form of food assistance

(SNAP, WIC, FMNP) 90% identified as African American, 93% as women About 50% had shopped at the RCFS farmers’ market

for 1 year Average age was 57 years (SD: 18 years) Purchased 480 fruits and vegetables (~4/person)

Most Popular Produce(purchased by at least 20% of customers)

PeachesMuscatine grapesPlumsTomatoesBananas* Sweet potatoesWatermelonPeanutsApples

Loved or liked the foods

To make fast and easy foods like salads, snacks, and smoothies or

juices.

Address specific health issues such as cholesterol, prenatal development,

and digestive functioning

For children or grandkids

“I always eat them that way”

“I was brought up using pork fat

and I’m not satisfied with the olive oil [in green beans].”

Audience-centered marketing Activity What communication strategies would you use to

encourage farmers’ market use among similar populations?

Building on key themes of: Food preferences - SLOGAN Food preparation plans – RECIPE CARD Health – SLOGAN Family – ONSITE ACTIVITY Tradition – ORGANIZATION OF MARKET

TEAM WORK10 minutes to create communication strategy10 minutes to report out (2 min/group)

Thank you!

daf96@case.edu

Question?