Market to Mouth – Coming Full Circle
What do people do with foods
purchased at a health centerbased 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
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
Journal of Clinical Oncology
Journal of Nutrition
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)
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
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
91,910
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
Engaging the Community
2012 D. Freedman transitioned
out of active leadership
Community
Visioning
Meeting
(11/2010),
N=50
Memorandum
of Agreement
(10/2010)
Advisory
Council (2/2011ongoing), Hire
Farmers’ Market
Manager
Freedman & Alia, 2013 -- manual
Farmers’ Market
opened June
2011; begins 4th
season June
2014
Customer and
Farmer
Satisfaction
Surveys
(ongoing)
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 Study
Why 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)
Peaches
Muscatine grapes
Plums
Tomatoes
Bananas*
Sweet potatoes
Watermelon
Peanuts
Apples
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 WORK
10 minutes to create communication strategy
10 minutes to report out (2 min/group)
Thank you!
daf96@case.edu
Question?