Strengthening population health efforts outside the walls of the hospital is not a new or innovative concept, but connecting social determinants of health and collaborating with diverse stakeholders is a newer strategy. In New Jersey, for example, poverty and food insecurity have increased in recent years, according to reports and community health needs assessment data, and so has chronic disease in underserved areas. Many of these social determinant issues can be prevented.
In May, Virtua, Southern New Jersey’s largest health system, launched a long-planned mobile farmers market program that would serve food desert and underserved communities in the system’s service areas [see "Some service area health statistics" at end of article]. Virtua has many other population health programs, but this one was unique in our experience. The mobile farmers market has three main objectives:
- Provide the poor with inexpensive produce to promote healthy eating options.
- Incorporate health education and health literacy about eating well and its connection to reducing chronic disease.
- Reduce food insecurity and hunger.
To fundamentally change the health of a community, Virtua believes we must evolve to a place where we can treat the community outside the walls of the hospital, before we ever see members of our communities as patients, if at all.
[Related: Determinants of Health Series on Food Insecurity]
Creating an outreach model
In Southern New Jersey, food insecurity and hunger affect nearly 200,000 people, including children, families and seniors. Food insecurity is directly related to poor health outcomes and linked to chronic disease.
There are many ways to treat these populations; but to reframe the approach to an outreach model, we had to rethink our health care system’s focus from sick care to well care. If outpatient service is the way of the future, we have to drive down the incidence of chronic disease and promote health and well-being with an innovative and uncomplicated approach. The idea for a solution came on four wheels — a mobile farmers market bus to drive to needy communities, taking fresh produce to the streets and neighborhoods that needed it the most. 
In theory, the program was quite simple, but the actual premise of this program was multifaceted. We asked ourselves both visionary and practical questions:
What if we employ registered dietitians to speak with patrons about their health and health issues while they shop? Can we be perceived as trusted health advisors on the streets, as we are in the hospitals?
What if we worked with graduate-level public health students to help us collect data to measure the effectiveness of the program, and measure healthy behavior change over time?
Because we are a health system, where will we obtain the produce?
The answers and the adventures were many. But the biggest supposition was on price point.
We knew that, as a health system, this program would operate as a community benefit initiative under our nonprofit status; but further, it would operate at a purposeful loss. We knew that to reach the populations with the greatest need, we had to cut produce costs deeply. Our thinking went something like this:
As you drive home at night, you will often see people pulled up to various fast-food chains, ordering a kid’s meal, a No. 1 combo meal, or some other menu item that these restaurants have ready to serve, hot or cold — affordable and quick comfort food that appeals to the masses.
What if a family of four could buy a week’s worth of fresh, nutritious produce for the same price as a burger, fries and soda combo? Does this work? Yes, it does. Customers who shop at the mobile farmers market are offered three bag-size options, based on family size.
Key partnerships
How can our organization afford this? With simple luck, we connected with a Whole Foods marketing executive who explained the company's commitment to healthy cities. After a few pitches of our idea, it was an instant collaboration. Whole Foods would sell us produce at a discounted rate, and we would disseminate it to the communities at a reasonable cost.
Whole Foods also offered to deliver our weekly produce orders to our home base of operations on their semitractor-trailers every Monday morning. It also helped to train our new team on ways to handle, clean and learn more about different fruits and vegetables. This was a tremendous relief to our leaders and staff.
Measuring the success of these efforts was critical to understanding this intricate “dance.” So Virtua partnered with nearby Drexel University in Philadelphia to hire master of public health students to staff the mobile market bus. These learners collect the data and help Virtua measure outcomes via surveys.
Virtua's mobile farmers market operates year-round and full time, which is atypical. Hunger is always present; thus, the need for an ongoing program was essential. With respect to the team to staff this program, we wanted to be thoughtful and representative of the communities we serve. We hired from the community and not only wanted to provide a good living wage to ensure that our workforce earned enough to be proud of their work, but also to ensure they, too, were not living in poverty.
Registered dietitians and mobile market coordinators work the daily heartbeat and outreach efforts of the program. The recipes, shared weekly with the market patrons, are all easy to assemble, with no special kitchen equipment required. Information about the market is shared in both English and Spanish.
When customers repeatedly use the program, the survey they take is shorter. We are simply looking for positive behavior change, such as increased produce consumption, overall health literacy awareness and implementation of recipes and feelings of overall health.
We are proud of this program and what it can accomplish. Do we think this is a wise investment? Absolutely [see "Early indicators of mobile market success", below]. We wholeheartedly believe the data will prove this in time.
Some service area health statistics
In Burlington County, N.J., a population of nearly 450,000 people, more than 41 percent of residents experience high blood pressure, 9 percent have been diagnosed with diabetes, 18 percent suffer from asthma and 11 percent of all households experience food insecurity. Burlington County’s Medicaid enrollment is 14.4 percent of the population — 64,712 people, according to the New Jersey Hospital Association’s spring 2017 Hospital Indicators Report. To add to those concerns, Burlington County has the second highest rate of homelessness in the state.
In Camden County, N.J., a population of nearly 500,000 residents, nearly 28.2 percent of the population is enrolled in Medicaid (143,914 people), 14 percent of homes are experiencing food insecurity and more than 28 percent of residents suffer from such chronic diseases as obesity, diabetes and heart disease. There is also a higher percentage of children living in single-family households.
Early indicators of mobile market success
The mobile farmers market’s accomplishments in May, its first month, include:
- Served about 280 families per week (a total of 1,114 families served).
- Visited 7-8 sites per week.
- Distributed more than 3,300 pounds of produce. (The program accepts SNAP benefits.)
- 70 percent of market patrons were women and children, and 30 percent were men.
- Registered dietitians were assigned to talk with patrons at each of the markets.
- Graduate-level public health students collected data to begin measuring outcomes. Sample survey questions and answers included:
- Have you worried recently about having enough food to eat three healthy meals a day? Forty percent of surveyed patrons answered "yes."
- In the last seven days, how many pieces of fresh fruit and vegetables have you consumed? Sixty percent had consumed fewer than 10 pieces [answer should be 35].
Virtua's mobile farmers market program continues to grow, with staff seeing an increase in families served over subsequent weeks.
For more information on this issue, see our Food Insecurity page with links to H&HN coverage and other AHA resources.
Suzanne Ghee is assistant vice president of business growth and community health engagement, and Alfred Campanella is executive vice president of strategic business growth and analytics, Virtua Health System, Marlton, N.J.
