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Darcy A. Freedman, MPH, PhD

Market to Mouth – Coming Full Circle What do people do with foods purchased at a health center-based farmers’ market?. Prevention Research Center for Health Neighborhoods Seminar May 14, 2014. Darcy A. Freedman, MPH, PhD

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Darcy A. Freedman, MPH, PhD

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  1. Market to Mouth – Coming Full CircleWhat do people do with foods purchased at a health center-based farmers’ market? Prevention Research Center for Health Neighborhoods Seminar May 14, 2014 Darcy A. Freedman, MPH, PhD Associate Professor, Department of Epidemiology and Biostatistics, Social Work Core Faculty, Prevention Research Center for Healthy Neighborhoods Case Western Reserve University

  2. 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

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

  4. Diabetes Care Journal of Nutrition Journal of Hypertension Journal of Clinical Oncology Journal of Nutrition

  5. 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

  6. Composite score = sum of scores for access to fresh fruit, fresh vegetables, lean meats, low-fat milk, tobacco products, alcohol. Chronbach’salpha = .76 Source: Freedman & Bell, 2009

  7. 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).

  8. 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)

  9. Freedman, Blake, & Liese, 2013

  10. Federally Qualified Health Center-based Farmers’ Market • FQHC Service Delivery Sites • South Carolina: 156 • Ohio: 148 • US: 7,621

  11. Study Context • Site selected (October 2010): • Family Health Centers, Inc., Orangeburg, SC • Orangeburg County ranked 45 out of 46 for county health rankings** • *US Census Bureau, **County Health Rankings

  12. Engaging the Community 2012 D. Freedman transitioned out of active leadership Freedman & Alia, 2013 -- manual

  13. Outcomes of the RCFS

  14. Individual-level Changein 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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!

  20. 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

  21. 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.

  22. 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)

  23. Coming Full Circle with Systems Change • Need to increase supply and demand for farmers’ markets

  24. 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)

  25. Most Popular Produce(purchased by at least 20% of customers) Peaches Muscatine grapes Plums Tomatoes Bananas* Sweet potatoes Watermelon Peanuts Apples

  26. 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

  27. “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].”

  28. 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 strategy 10 minutes to report out (2 min/group)

  29. Thank you! daf96@case.edu

  30. Question?

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