The Appalachian (F)armacy

An initiative to improve Health

outcomes of low income families

K. Munene Mwirigi, M.P.A., M.S. DrPH(c)

RHAT 24th Annual Conference Theme:

Rural Healthcare Infrastructure: Vital to Population Health

Introductions

• Who do we have here today?• Name

• County/region

• Occupation/ area of practice

• Why you come to this presentation

Introduction

• What is Food Insecurity?

• Why does food quality matter?

• Food security and health

• Farmacy Program

• Recommendations and opportunities for the community

• Summary

Food Insecurity“Access by all members of the household at all times to enough food for an active

healthy life”

• USDA food insecurity scale– “when a participant reports 3 or more food-insecure conditions on the survey” These includes-

• Low food security- reports of reduced quality, variety, or desirability of diet

• Very low food security- multiple indications of disrupted eating patterns and reduced

intake

Prevalence of food insecurity in the US 2001- 2017

USDA, Economic Research Service using data from U.S. Department of Commerce,

U.S. Census Bureau, Current Population Survey Food Security Supplement.

Assessing for Food Insecurity

• I’m going to read you two statements that people have made about their food situation. For each statement, please tell me whether the statement was often true, sometimes true or never true for your household in the last 12 months/ 1 month.

1. “We worried whether our food would run out before we got money to buy more.”

2. “The food that we bought just didn’t last, and we didn’t have money to get more.”

A response of “often true” or “sometimes true” to either question = positive screen for Food Insecurity

Food Insecurity in TN

Counties with highest rates (>20%)

Lauderdale, Lake, Hardeman, Haywood, & Shelby

2016 Overall food insecurity in TN

• In Tennessee, 14.5% (about 1 M) of

the population was food insecure in

2015. (National 12.3%)

Feeding America. (2016). Food insecurity in Tennessee. Retrieved from http://map.feedingamerica.org/county/2016/overall/tennessee

Food insecurity and income level

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Food Access-Farmers markets & local stores

• Health & nutrition literacy

• Case management• Improved care

Nutrition & Health Knowledge

Social cohesion and interaction

Food insecurityLocal economy-farmers and local business

Food insecurity and food quality

• Food insecure households deploy coping

strategies, such as seeking calorically

dense and satiating foods that are often

nutritionally inadequate.

• Poor diet quality characterized by high

consumption of empty calories and low

consumption of fruits and vegetables.

• Changes in dietary consumption contribute

to negative physical and mental outcomes

and an increased risk for disease.

Holben, D., & Marshall, M. (2017) Position of the Academy of Nutrition and Dietetics: Food

Insecurity in the United States. JAND, 117(12).

Food insecurity and chronic illness• Food insecurity has a bidirectional relationship with chronic

illness

• Report by USDA ERS (2017) using NHIS data• Food insecurity is a better predictor of chronic illness than income.

• Associated with all 10 chronic illnesses vs income with only 3.• hypertension, coronary heart disease, hepatitis, stroke, cancer, asthma,

diabetes, arthritis, chronic obstructive pulmonary disease, and kidney disease

• Food security status is also strongly related to the likelihood of chronic disease in general, to the number of chronic conditions reported, and to self-assessed health

• Berkowitz et al. study (2014) NHIS Data• 1 in 3 chronically ill patients were unable to afford food, medications,

or both

• Food Insecure adults more likely to report cost related medication under use

Gregory, C. A., & Coleman-Jensen, A. (2017). Food Insecurity, Chronic Disease, and Health

Among Working-Age Adults.

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

Chronic illnesses in Tennessee

• Chronic illnesses now account for 7 of the top 10 causes of death in

the US. (2014)

• Tennessee ranks 45th on the America’s Health Rankings

• Premature Death (years lost before the age of 75)-

– about 1 per every 10 deaths (Ranks 43rd)

• Rates in Tennessee

– Obesity 35% (U.S. 30%)

– Diabetes 13% (U.S. 10%)

– Cardiovascular Disease 9% (U.S. 6%)

– Hypertension 39% (U.S. 31%)

United Health Foundation. (2018). America’s Health Rankings

Food Insecurity- Summary

• Consequences– Affects food quality

– Associated with medication underuse

– Associated with poor health outcomes

– Associated with chronic illness

– Better predictor of chronic illness than income

What are your thoughts?

• Do you resonate with any of this information?

• How do you assess for food insecurity in your

practice? Do you?

• What are your thoughts on food insecurity as a

risk factor for health?

Food Assistance Programs &

Healthy Incentives Programs• We know all about SNAP, WIC

• SNAP eligibility is at or below 130% of the federal poverty line-– 16,000 per year for 1 person and 33,000 for a household of 4

• SNAP lacks restrictions that promote purchase of healthy food items.

• SNAP participants have lower food quality, lower fruits and vegetable intake and higher empty calorie intake compared to non-SNAP participants of the same income level

• Healthy Incentives programs provide incentives to SNAP participants– To increase access and encourage purchase of fresh fruits and vegetables.

– These programs use tokens or vouchers and are mostly found in farmers’ markets

(Nguyen, Shuval, Njike, & Katz, (2014) The Supplemental Nutrition Assistance Program

and Dietary Quality Among US Adults: Findings From a Nationally Representative

Survey

The mechanism of Food Assistance Programs

IOM (Institute of Medicine) and NRC (National Research Council). 2013. Supplemental

Nutrition Assistance Program: Examining the evidence to define benefit adequacy.

Washington, DC: The National Academies Press.

Why fruits and vegetables?

• Very low consumption rates in Tennessee

– Tennessee ranks 47th in Fruits and veggie consumption

– Only 7% of the population meets the standard in TN

– Even lower rates for low income households

• Nutrient dense & Health outcome

– Fruits and vegetables provide a variety of nutrients that

improve the diet quality and improve health outcomes

• Access and affordability

– Fruits and vegetables are expensive and less available in

rural areas.

The State of Obesity. (2011). Fruits and vegetable consumption.

USDA recommendations of about 2 cups per day of

fruit and about 3 cups per day of vegetables

Food Insecurity Nutrition Incentives

• FINI was created under the 2014 Farm Bill– Created to develop strategies to improve diet quality of SNAP

participants by providing incentives for fresh produce

– Provide 50/50 match grants to nonprofit and state/local government agencies

– Programs provide point-of-sale incentives- e.g. coupons

– Types of grants under FINI • FINI pilots: ≤ $100,000 over ≤ 1 year

• FINI projects: ≤ $500,000 over ≤ 4 years

• FINI large scale projects: ≥ $500,000 over ≤ 4 years

– Examples include AARP foundation, Wholesome wave

• 2018 Farm Bill has not yet been passed.

• Point-of-sale incentives– Currently provide incentives for fresh fruits and vegetables

– Emphasize utilization of farmers markets

– Improve the local economy and support local farmers

Appalachian Farmacy

• Farmacy initiation– Awarded a FINI pilot grant for $100,000

– Started in July 2017• July to October- Farmers markets

• November to March at Food City locations

• Farmacy Aims:– Increase the purchase and consumption of locally

produced, fresh fruits and vegetables at Washington County farmer’s markets by providing vouchers and nutrition education

• Food Insecurity Nutrition Incentives Grant– Appalachian Resource Conservation &

Development Council (ARC&D)

– Appalachian Sustainable Development (ASD)

• Evaluation– ETSU College of Public Health

• Implementation sites– Johnson City Community Health Center

(CON/JCCHC)

– Johnson City Senior Center (JCSC)

– Jonesborough Senior Center (JBSC)

– 3 Farmers Markets

– Food City (produce section only)

• Nutrition classes– University of Tennessee Extension (UT)

Washington County

Multi-Partner!!

Appalachian Farmacy

Health

Assessment

JCCHC

Senior centers

Vouchers

Monthly $28- $112

depending on

household size

Redemption

Farmers

Market

& Food City*

Nutrition

classes

UT Extension

• Free fruits and vegetable vouchers given as prescriptions

• Coalition team met monthly

Evaluation design

• Mixed methods approach

• Quantitative- Survey– Baseline

– Midpoint – after Farmer’s markets closed

– 6 months

• Qualitative – Intercept interviews (n=22)

– 2 focus groups (n=11)

• Thematic analysis

• Data analysis on SPSS

Survey instruments

• Survey format– Pre-, Mid-,& Post-

– Similar questions

– 14- 19 questions

– Self or staff administered

• Assessed– Fruits & Veggie Intake

– Types of produce bought

– Cooking habits

– Food insecurity

– Perceptions of fruits and veggies

– Physical Activity

Qualitative

• Intercept interviews- n=22– Developed Interview scripts

– 15 minute interviews on perceptions of Farmer’s Market and the program

– About 6 interviews in Spanish

– Participants approached at the Farmer’s Market during check-in

– Incentive was 5 extra tokens

• Focus group guides- n=11 (2 sessions)– 1 hour session on perceptions of the program, Fruits

and vegetables, and health

– Verbatim note taking

Data Management

• Qualitative Data– Separately reviewed transcripts

– Coded scripts based on guide

– Jointly Identified recurrent themes

• Quantitative data– Developed a coding sheet

– Entered information into Excel

– Entered data into SPSS

– Descriptive analysis; T-test comparison of means

– Calculated Food insecurity

Baseline Results

Variable TN Wash.Farmacy

N=134

Adults with some college 67% 59% 43%

SNAP eligible food

insecure adults56% 61% 79%

Obesity 32% 29% 53%

Less than a fruit daily 46% n.d 73%

Less than a vegetable

daily25% n.d 72%

No physical activity 30% 32% 43%

Feeding America (2015) Food insecurity | County Health Rankings (2018) |

The State of Obesity(2011) fruits and vegetable consumption

Quantitative Results

• Recruited over 150 participants

• Distributed about $50,000 worth of vouchers

• 60% redeemed at Farmers Markets

• HH with 4 or more accounted for 33% of the participants and spent 53% of the funds

• Mean consumption increased (α= .05)– Fruits from 4-6 times weekly to 2 times daily

– Vegetables from 4-6 times weekly to once daily

– Types of fruits consumed rose from 5 to 8

– Types of veggies consumed rose from 6 to 11

Redemption data

July Aug Sept Oct Nov Dec Jan Feb Mar

Total amount $3,535 $5,992 $6,440 $7,070 $3,332 $4,029 $4,382 $2,408 $1,813

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Month

ly r

edem

ption

Monthly redemption by participants at the farmers market and Food City

• 60% redeemed at Farmers Markets

Qualitative Results

“…I would not have been able to buy fruits and veggies for my kids"

“Helps stretch my dollars”

“things you wouldn’t buy otherwise”

Access

“Going to market gets me out of the house and gives me something to look forward to “

“I got some recipes, some hints about how to freeze“

Social cohesion

“works my bowels"

“Diet is helping. Blood sugar has decreased”

“feeling a whole lot better"

Perceptions of health

Challenges and Gaps

• Finding partnerships– Finding partners to give financial and technical support at the

local level

• Program administration– The program requires extensive planning and administration

which can be expensive and time consuming• May require a fulltime staff

– Obtaining adequate incentives/funds to meet the needs of the local community

• Finding adequate funding and partnerships locally.

• Meeting the 50/50 match requirement

Challenges and Gaps

• Staffing– Case management- important for retention and success of the

program• Clinic verses the senior centers

– Program administration- centralized management of the program • Fulltime program administrator

– Community engagement- recruitment, education and promotion efforts

• Community partnerships, advertising

• Access– Transportation services/ management for some participants

• Local buses, institution buses,

• Synchronization with other appointments- doctor’s visits etc

– Proximity to farmers markets/ fresh produce• Opening farmers’ markets increasing farmers’ market days

Recommendations

• Promoting health– Although food insecurity didn’t improve very much, this indicates that there is a greater

need

– Improving food insecurity, despite limited funding, through nutrition education, community partnerships (farmers, markets, local government, non-profits).

– Promoting other non-nutrition health programs that improve health- physical activity programs, smoking cessation programs,

• Case management– Participants require accountability, guidance, & reminders to ensure success of the

program

– Participants have unique needs that make it challenging to participate. For example language barrier, transportation, illness, cultural differences

• Partnerships– Across agencies, institutions and the community

What are your thoughts?

• Any questions on the program design,

implementation or evaluation?

• Do you know of a similar program in your area?

• Are there opportunities for such a program in

your community?

Appalachian Farmacy Committee and partners during the

launch at the Johnson City’s Farmers Market in downtown

Johnson City.

Acknowledgement

For More Information

K. Munene Mwirigi

Mwirigi@etsu.edu