Developing, Implementing, &

Sustaining Healthy Food

Incentive Programs at

Farmers’ Markets

Darcy Freedman, MPH, PhD

Associate Professor, Epidemiology,

Biostatistics, & Social Work

Associate Director, Prevention Research

Center for Healthy Neighborhoods

Case Western Reserve University

January 29, 2015

Disclosures

This research is a product of the University of South Carolina (USC)

Prevention Research Center, supported by Cooperative

Agreement Number 3U48DP001936 for the USC Cancer Prevention

and Control Research Network, and by the Prevention Research

Center for Healthy Neighborhoods at Case Western Reserve

University, supported by Cooperative Agreement Number

1U48DP005030, both awarded by CDC.

I do not have conflicts of interest, real or perceived, related to this

presentation. Results and information presented are the views of

the author and do not necessarily represent the official position of

the CDC.

Acknowledgements

Family Health Centers, Inc.

• Leon Brunson, Sr.

• Sandra Stephens, MD

• Edith Anadu, PhD

• Elvin Cobbs

Right Choice Fresh Start Farmers’ Market

• Paul Butler

• Sylvia Ellis

South Carolina Primary Health Care Association

• Vicki Young, PhD

University of South Carolina, Cancer Prevention and Control Research Network

• Daniela Friedman, PhD (PI)

• James Hebert, ScD (PI)

• Heather Brandt, PhD

• Kassy Alia, MS

• Amy Mattison-Faye, MPH

• Jason Greene, MPH

• Aaron Guest

• Kathryn Kranjc

• Thomas Hurley, MS

• Seul Ki Choi, MPH

Presenter’s Background

RiverWestProduce Stand

Nashville, TN

(2005-06)

Veggie ProjectNashville, TN

(2007-09)

Right Choice Fresh Start FMOrangeburg, SC (2009-14)

FreshLink

Cleveland, OH

(2014-present)

FM Tracks

Multi-state

(2014-present)

Presentation Objectives1. Identify the need for healthy food access interventions and the

benefit of making linkages between Extension, public health,

and community health center systems.

2. Describe a successful healthy food incentive program (Shop N

Save) piloted in rural South Carolina.

3. Identify methods for engaging key stakeholders (e.g., farmers,

community members, health care providers, elected officials,

researchers) to support and sustain healthy food incentive

programs at farmers’ markets through policy change.

4. Name at least three opportunities and challenges related to

wide-scale implementation of healthy food incentive programs

at farmers’ markets.

WHY ARE HEALTHY FOOD

INCENTIVE PROGRAMS NEEDED?

5 servings F/V per day

See Wang et al., 2014, BMJ

Eating at least 5 servings of fruits and vegetables

daily is associated with decreased risk

of all cause mortality.

Few Americans Consume Diet

Rich in Fruits and Vegetables

CDC, 2013

Median Daily Vegetable Intake among Adults in the U.S.

Percentage of U.S. Adults Consuming 5+

Fruits and Vegetables per Day

0

10

20

30

40

50

60

70

80

90

100

1996 1998 2000 2002 2003 2005 2007 2009

Pe

rce

nt

Source: CDC BRFSS

Date of download: 9/29/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Trends in Dietary Quality Among Adults in the United States, 1999 Through 2010

JAMA Intern Med. Published online September 01, 2014. doi:10.1001/jamainternmed.2014.3422

Alternate Healthy Eating Index 2010 Score Without the trans Fat Component According to Socioeconomic Status (SES) by National Health and Nutrition Examination Survey

CycleSymbols indicate covariate-adjusted means, and error bars, 95% confidence intervals. Participants with more than 12 completed years of education attainment and a

poverty income ratio of at least 3.5 were categorized as high SES; participants with less than 12 years educational attainment and a poverty income ratio of less than 1.30 were

categorized as low SES; and others were classified as medium SES. Values were estimated from multivariate linear regression analysis by adjusting for total energy intake

(continuous), sex (male, female), age group (20-39, 40-64, ≥65 y), race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American, other), and household size.

Figure Legend:

Gap between High SES

and Low SES was

3.9 in 1999 and 7.8 in 2010

1 in 3 National Health

Interview Survey

participants who

were chronically ill

reported they were

unable to afford

food, medications, or

both. (Berkowitz et al., 2014)

Hunger in America, 2014

Costs of Eating

Fruit & Vegetable Options

Snack Cost ($)

per Portion

Fruit or

Vegetable

Alternative

Cost ($) per

Portion

Difference in

Price ($) per

Portion

Cookie 0.16 Apple 0.36 +0.20

Graham

Cracker

0.14 Grapes 0.32 +0.18

Crackers 0.16 Carrots 0.19 +0.03

Pretzel 0.25 Red pepper 0.60 +0.35

Total Additional Costs 0.76

Family of 4 switches to fruit and veggie snacks:

$0.76/person/day x 7 days x 4 = $21.28/week

Additional Cost = $85.12/month

Source: USDA, Economic Research Service (11/28/2012)

http://www.ers.usda.gov/data-products/fruit-and-vegetable-prices.aspx#33646

Costs of Eating

Fruit & Vegetable Options

Snack Cost ($)

per Portion

Fruit or

Vegetable

Alternative

Cost ($) per

Portion

Difference in

Price ($) per

Portion

Cookie 0.16 Apple 0.36 +0.20

Graham

Cracker

0.14 Grapes 0.32 +0.18

Crackers 0.16 Carrots 0.19 +0.03

Pretzel 0.25 Red pepper 0.60 +0.35

Total Additional Costs 0.76

Family of 4 switches to fruit and veggie snacks:

$0.76/person/day x 7 days x 4 = $21.28/week

Additional Cost = $85.12/month

Source: USDA, Economic Research Service (11/28/2012)

http://www.ers.usda.gov/data-products/fruit-and-vegetable-prices.aspx#33646

The average SNAP benefit

per person is about $125

per month, which works out

to about $1.40 per person

per meal

WHO HAS EXPERTISE RELATED TO

HEALTHY FOOD INCENTIVE

PROGRAM IMPLEMENTATION?

See Freedman et al., (2014) Extending Cancer Prevention to Improve Fruit and Vegetable Prevention.

Journal of Cancer Education.

Cooperative Extension

Community Health

Centers

Public Health

Systems

The “Three Sisters”

RIGHT CHOICE FRESH START

FARMERS’ MARKET EXAMPLE

Forming the Right Choice Fresh Start Farmers’ Market

Federally Qualified Health

Center (FQHC) based farmers’ market

Formed at as community-university

partnership between University of

South Carolina (USC) and

Family Health Centers, Inc.

Supported through the USC

Cancer Prevention and Control

Research Network (CPCRN) funded

by CDC through the Prevention

Research Center Special Interest

Project (SIP) Program

FQHC Service Delivery Sites

• South Carolina: 156

• US: 7,621

Context of RCFS• 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

Community Readiness Assessment

Text, chart and/or photo here.

For more information see: Freedman et al. (2012). Journal of Community Health, 37, 80-88.

Engaging the Community

Memorandum of Agreement (10/2010, renewed annually)

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

Advisory Council (2/2011-ongoing); Establish Vendor Policies; Hire Farmers’ Market Manager

Farmers’ Market opened June 2011; 4th season opened June 6, 2014; Customer and Farmer Satisfaction Surveys (ongoing); Events at market

Seek additional funding: SC Cancer Alliance, CTG, Farm Bureau, USDA Community Food Project

2012 D. Freedman transitioned

out of active leadership

Freedman & Alia, 2013 “Building Farmacies” manual

1. Study population: Diabetic patients from the FQHC

2. Dose-response relationship between farmers’ market use and

improvement in fruit and vegetable consumption.

3. Patients who relied exclusively on incentives to purchase

produce at the RCFS farmers’ market experienced greater

improvements in fruit and vegetable consumption.

Key Findings from Initial RCFS Evaluations

For more information see: Freedman et al. (2013). Preventive Medicine, 56(5), 288-292.

Who?

Anyone shopping with federal food assistance at the RCFS

farmers’ market (SNAP, WIC, & Senior or WIC Farmers’ Market

Nutrition Program)

What?

Provide one $5 match for spending $5 or more with federal food

assistance at the RCFS

When?

Available throughout the season. One match per market day.

Shop N Save

Why?

Low use of RCFS by SNAP beneficiaries during first season

Concern among Advisory Council and Farmers

Findings from RCFS evaluations – incentives mattered to

improve diet

Reality of economic barriers to accessing healthy foods

Behavioral economics

Shop N Save

Strong demand for Shop N Save

336 enrollees in 2012 (first year)

617 in 2013 (second year)

Characteristics of Shop N Save (SNS) Participants in 2012

58% had NEVER been the RCFS before enrollment in SNS

91% women, 90% African American

54% patients at the FQHC

High rates of self-reported diet-related health impairments:

o High blood pressure (51%)

o Diabetes (30%)

o Arthritis (30%)

30% reported health status was “fair” or “poor”

Key Findings from Shop N Save EvaluationFor more information see: Freedman et al. (2014). Preventing Chronic Disease, 11(E87). http://dx.doi.org/10.5888/pcd11.130347

Types of Federal Food Assistance among SNS Participants

Key Findings from Shop N Save EvaluationFor more information see: Freedman et al. (2014). Preventing Chronic Disease, 11(E87). http://dx.doi.org/10.5888/pcd11.130347

0 20 40 60 80

SNAP

WIC

WIC FMNP

Senior FMNP

SNAP: Supplemental Nutrition Assistance Program, FMNP: Farmers’ Market Nutrition Program,

WIC: Supplemental Nutrition Assistance Program for Women, Infants, and Children

Food Assistance Revenue Before and After

Shop N SaveFor more information see: Freedman et al. (2014). Preventing Chronic Disease, 11(E87). http://dx.doi.org/10.5888/pcd11.130347

SNAP use ↑ 4-fold

Senior FMNP use ↑ nearly 4-fold

WIC use relatively unchanged

Food Assistance Revenue Before and After

Shop N SaveFor more information see: Freedman et al. (2014). Preventing Chronic Disease, 11(E87). http://dx.doi.org/10.5888/pcd11.130347

First and Last Week FMNP

Total Revenue at RCFS Farmers’ Market

Before and After Shop N SaveFor more information see: Freedman et al. (2014). Preventing Chronic Disease, 11(E87). http://dx.doi.org/10.5888/pcd11.130347

Significant increase in revenue from $14,285 to $15,720

http://epbiwww.case.edu/index.php/people/faculty/191-dfreedman

More Information on the Right Choice Fresh

Start Farmers’ Market

MOVING FROM PILOT PROJECT

TO POLICY CHANGE

Documentary film to disseminate the story of RCFS

o Community forums

o Film festivals

o “Planting Healthy Roots”

http://www.youtube.com/watch?v=viPtYFwzD6I

Papers, Reports, Newspaper Articles, Radio Shows, Presentations

http://epbiwww.case.edu/index.php/people/faculty/191-dfreedman

One-on-one conversations with catalysts for policy change

o Poverty-rights advocates

o Agriculture and public health sectors

o Social workers

Sharing Our Story to Promote Wide-Scale

Implementation of Shop N Save

South Carolina Budget Proviso

38.26. (DSS: SNAP Coupons) The Department of Social Services shall

establish a program to provide coupons that will allow Supplemental

Nutrition Assistance Program (SNAP) recipients to obtain additional

fresh fruits and vegetables when purchasing fresh produce at grocery

stores or farmers markets with SNAP benefits through their EBT

cards. Each coupon shall allow the beneficiary to double the amount of

produce purchased, up to five dollars. The agency shall utilize all funds

received in the prior and current fiscal years from the U.S. Department of

Agriculture as a bonus for reducing the error rate in processing SNAP

applications to fund the program.

To develop recommendations for an implementation plan

To advocate for recommendations to be implemented

To identify and help recruit sites

To help with outreach and publicizing of the program

Engaging Stakeholders

Challenge to engage 2 primary stakeholders from the

beginning: SNAP recipients and farmers’ markets

Used supporting survey data collected from SNAP recipients in

South Carolina to develop recommendations

Engaging Stakeholders

SNAP participants in SC want to purchase fresh healthy foods at farmers’ markets. The Midlands Family Study included 550 adults caring for children,

69% participating in SNAP. One in three of these participants shopped at

farmers’ markets, and 97% said they would use their SNAP benefits at a

farmers’ market if a participating one was close by to them. Shopping at

farmers’ markets may help alleviate child hunger, too, as families that

shopped at farmers markets reported being more food secure, including

being able to protect their children from hunger.¹Jones, S. et al (2013). [Midlands Family Study]. Unpublished raw data.

Focus only on SNAP vs. other nutrition assistance groups vs.

Medicaid

Evenly distribute proviso funds to SNAP recipients vs.

concentrating in certain locations?

Amount of incentive?

Farmers’ markets vs. grocery store vs. buying vs. direct farmers?

First come, first serve vs. one-time only participation vs. multiple

time participation?

Coupons distributed at Department of Social Services offices and

other community locations vs. at participating sites?

Questions to Consider for Implementation Plan

Development

Pilot year (2014) – will continue in 2015

6 farmers’ markets, 1 mobile market, 1 food distributor

SNAP recipients using $2.50 of their own SNAP money on

produce = $5 in “Healthy Bucks” for more produce purchases

Reimbursement form to be filled out by site to turn into DSS

(Name, EBT card number, signature, “healthy bucks” amount)

South Carolina Policy Implementation Plan

Some Implementation Plan Challenges

Difficult to find farmers’ markets with the capacity to or interest

in participating

Location of farmers’ markets

Need for clear communications especially with turnover in

staffing involved with Healthy Bucks

1. Partner early and often.

2. Location, location, location.

3. Imagine wide-scale implementation before developing policy.

4. Language matters.

5. Evaluate and Disseminate

Lessons Learned in South Carolina

FUTURE DIRECTIONS FOR HEALTHY

FOOD INCENTIVE INTERVENTIONS

AT FARMERS’ MARKETS

1. Food Insecurity Incentive Grant Program (USDA)

2. FreshLink Peer Health Advocate

3. FM Tracks App

Future Directions

Thank you!

Darcy Freedman: daf96@case.edu

References • Berkowitz, S. A., Seligman, H. K., & Choudhry, N. K. (2014). Treat or eat: food insecurity, cost-related

medication underuse, and unmet needs. American Journal of Medicine, 127(4), 303-310.e303. doi:

10.1016/j.amjmed.2014.01.002

• Freedman, D. A., & Alia, K. A. (2013). Building "farmacies": A guide for implementing a farmers' market at

a community health center. Columbia, SC: University of South Carolina.

• Freedman, D. A., Choi, S. K., Hurley, T., Anadu, E., & Hebert, J. R. (2013). A farmers' market at a federally

qualified health center improves fruit and vegetable intake among low-income diabetics. Preventive

Medicine, 56(5), 288-292. doi: doi.org/10.1016/j.ypmed.2013.01.018

• Freedman, D. A., Mattison Faye, A., Alia, K., Guest, M. A., & Hebert, J. R. (2014). Comparing farmers’

market revenue trends before and after the implementation of a food assistance monetary incentive

intervention. Preventing Chronic Disease.

• Freedman, D. A., Pena-Purcell, N., Friedman, D. B., Ory, M., Flocke, S., Barni, M. T., & Hebert, J. R. (2014).

Extending Cancer Prevention to Improve Fruit and Vegetable Consumption. Journal of Cancer

Education. doi: 10.1007/s13187-014-0656-4

• Freedman, D. A., Whiteside, Y. O., Brandt, H. M., Young, V., Friedman, D. B., & Hebert, J. R. (2012).

Assessing readiness for establishing a farmers' market at a community health center. Journal of

Community Health, 37(1), 80-88.

• Centers for Disease Control and Prevention. (2013). State indicator report on fruits and vegetables, 2013.

Atlanta, GA.

• Wang, D. D., Leung, C. W., Li, Y., Ding, E. L., Chiuve, S. E., Hu, F. B., & Willett, W. C. (2014). Trends in dietary

quality among adults in the United States, 1999 through 2010. JAMA Intern Med, 174(10), 1587-1595. doi:

10.1001/jamainternmed.2014.3422

• Wang, X., Ouyang, Y., Liu, J., Zhu, M., Zhao, G., Bao, W., & Hu, F. B. (2014). Fruit and vegetable

consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and

dose-response meta-analysis of prospective cohort studies. BMJ, 349. doi: 10.1136/bmj.g4490

Questions?