Download - Darcy A. Freedman, MPH, PhD
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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
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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
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1 in 3 National Health Interview Survey participants who were chronically ill reported they were unable to afford food, medications, or both.
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Journal of Nutrition
Diabetes Care
Journal of Hypertension
Journal of Nutrition
Journal of Clinical Oncology
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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
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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
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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).
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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)
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Freedman, Blake, & Liese, 2013
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Federally Qualified Health Center-based Farmers’ Market
FQHC Service Delivery Sites• South Carolina: 156• Ohio: 148• US: 7,621
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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 91,910
African American, 2011* 28.1% 62.3%
Median household income, 2006-10* $43,939 $32,849
Person 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
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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
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Outcomes of the RCFS
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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
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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
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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
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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
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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
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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!
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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
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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.
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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)
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Coming Full Circle with Systems Change
Need to increase supply and demand for farmers’ markets
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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)
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Most Popular Produce(purchased by at least 20% of customers)
Peaches
Muscatine grapes
Plums
Tomatoes
Bananas*
Sweet potatoes
Watermelon
Peanuts
Apples
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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
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“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].”
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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 WORK
10 minutes to create communication strategy10 minutes to report out (2 min/group)
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Question?