As a whole, Nassau County residents enjoy a high standard of living. In 2012, the county’s median household income of $97,049 ranked it 13th in the nation; in comparison, the median household income in New York State overall was just $57,683. Nonetheless, immense inequalities exist between the county’s communities. Eight of nine high-need villages identified in the County Community Health Assessment have large minority populations: Elmont, Freeport, Glen Cove, Hempstead, Inwood, Roosevelt, Uniondale, and Westbury. In 2012, just 19.4% of residents in these select communities identified themselves as non-Hispanic white, compared to 72.1% in the rest of the county. The average median household income in the select communities was just $69,590, over $27,000 less than the county median, while 13.4% of individuals in these communities lived below the poverty level versus 5.8% countywide.
Chronic disease is a primary driver of elevated morbidity and mortality among non-Hispanic blacks and Hispanics. From 2009-2011, non-Hispanic blacks and Hispanics experienced elevated rates of hospitalization for asthma, heart disease, and diabetes compared to non-Hispanic whites and Asians/Pacific Islanders. Non-Hispanic blacks also experience elevated mortality from heart disease and diabetes compared to non-Hispanic whites and Asians/Pacific Islanders, while Hispanics had a higher rate of diabetes mortality but a lower rate of heart disease mortality. Disproportionate cancer burdens also contribute to health inequity in the county. Though lung cancer incidence is highest among non-Hispanic whites, non-Hispanic blacks experience elevated colorectal incidence, prostate cancer incidence, and breast cancer mortality compared to other groups in the county (NYS DOH, 2013).
The practice, "Recipes for Health", has been implemented (July 2014) by the Nassau County Department of Health's Bureau of Minority Health, in partnership with the Roosevelt Farmers Market, sponsored by the Roosevelt Community Revitalization Group Inc. Each week of the 10 week Sunday Farmers Market, one recipe is featured at the Department of Health tent. The featured recipe is available to distribute to customers shopping at the market along with other informational brochures relating to chronic disease, and healthy eating. A sample of the prepared featured recipe is offered along with a display of the farmers' market ingredients used in the recipe. Those who visit the tent for a sample is asked to complete a short survey about the recipe and sample. The survey is either staff administered or self-administered and is available in English and Spanish. The participants are given the option to have the surveyor record their responses for them because significant number of them participated after purchasing their produce and have items in their hands already.
According to Healthy People 2020 (2014), diet and body weight are related to health status. Good nutrition is important to the growth and development of children. A healthful diet also helps individuals reduce their risks for many health conditions like Type 2 diabetes, heart disease, and obesity. Therefore, the goal of "Recipes for Health" is:
- To promote healthy eating with foods prepared with fresh ingredients.
The objectives are:
-To offer a recipe each week during the community Farmer's Market using the produce purchased at the Farmer's Market
- Make available a sampling of foods prepared in a healthful manner and perhaps different from what the population may be used to.
- Offer additional supportive materials regarding healthy eating and chronic disease management
The goal and objectives were both met. The promotion of healthful eating was provided at the community farmer's market whereby 30% - 50% of the patrons were engaged in the initiative. 23% of those engaged completed a survey. Numerous patrons (no actual data) including those engaged in the sampling took home supportive materials. Verbal feedback was also received from patrons who stated they enjoyed the recipes provided. Some said they made the recipe at home in the week following its feature, and some verbalized their excitement regarding the upcoming recipes and samples. The factors that led to the success of the practice was the collaborative efforts of the health Department and the community Farmer's Market by providing individuals the needed tools, knowledge and skills in order to make healthier choices and prepare fresh ingredient recipes which reduce the intake of saturated and trans fats, cholesterol, added sugars, and sodium (salt). Every recipe uses at least one fresh, healthy, and nutritious ingredient so individuals learn to use whole foods in daily meal preparation and there are some healthy alternative substitutions for refined foods as well.
The Nassau County Bureau of Minority Health strives to increase access to and knowledge about healthful foods in select communities, which is a priority in Healthy People 2020. The USDA has deemed many areas of Long Island “food deserts”, including our target communities of Hempstead and Roosevelt. A food desert is an area in which residents have poor access to supermarkets that sell healthy, affordable foods (USDA, 2014). Though the exact relationship between food deserts and health remains unclear, research has found a correlation between food access and chronic disease. Food deserts are most common in lower-income, minority communities. Grocers that do stock healthy options in these communities often sell low-quality items as well as sell at elevated prices. Moreover, even in areas with accessible and affordable healthy foods, residents may not have the time or knowledge to cook healthily (Story, 2008). Also, minorities often have lower levels of health literacy than non-minorities. Thus, improving access alone will not change behavior; successful initiatives must couple improved access with increased knowledge and affordability.
In the past, the Bureau of Minority Health has addressed the issue of chronic disease, diet, access, and utilization of healthful foods during the "Soul Food Junkies" initiative which was awarded Promising Practice in 2014. This practice is an educational series presented in minority communities which included the award winning documentary "Soul Food Junkies', a medical provider panel, and a healthy food demonstration.
To improve healthy food access and utilization in Nassau County’s minority communities, the Bureau of Minority has partnered with the Roosevelt Community Revitalization Group to run weekly summer farmers markets for 10 Sundays in Roosevelt, one of our select communities. Community members are able to use EBT (food stamps) and WIC benefits to purchase fresh fruits and vegetables at the markets. Moreover, the Bureau distributed weekly healthier option recipes which can be prepared using items sold at the market, as well as educational materials regarding healthy eating and chronic disease. A prepared sample of the featured recipe was also available along with a display of the ingredients used from the market in the recipe. The Bureau is also developing a “Cooking Fresh” cookbook which will be distributed for free at Farmers Markets in 2015.
1,500 people attended the Farmers Markets during the 10 weeks in 2014. An average of 34% participated in the initiative. The survey was offered to farmer’s market patrons who approached the tent and tasted the featured recipe sample. 23% completed the survey. (Six) 6 respondents preferred the survey in Spanish translation, which was available. All others completed the survey in English.
A total of 74 surveys were completed over the course of 10 weeks. Samples were offered at five of the ten days the farmer’s market was open. A total of 1500 visitors attended the famers market over the course of the 10 weeks.
"Recipes for Health" is an innovative tool created from evidence-based Recommended Strategies and Measurements to Prevent Obesity, Strategy #2 of MMWR Strategies to Promote the Availability of Affordable Healthy Food and Beverages
As per the CDC, Limited availability of healthier food and beverage options can be a barrier to healthy eating and drinking. Healthier food and beverage choices include, but are not limited to, low energy dense foods and beverages with low sugar, fat, and sodium content (11). The collaborative efforts of the local health department and the community farmers market made available healthier food and beverage choices (e.g., fruits, vegetables, and water) and made available recipes using fruits, vegetables and water in an effort to increase the consumption of healthier foods.
Nutrition, Physical Activity, and Obesity
The goal of "Recipes for Health" is to promote healthy eating with foods prepared with fresh ingredients. There are three (3) objectives.
1. To offer a recipe each week during the community Farmer's Market using the produce purchased at the Farmer's Market
2. Make available a sampling of foods prepared in a healthful manner and perhaps different from what the population may be used to.
3. Offer addition supportive materials regarding healthy eating and chronic disease management
The steps taken to implements the program were as follows:
Identify a current public health issue effecting a particular community
Incorporate a new idea within an existing recommended practice
Identify and engage community stakeholder(s)
Create a viable initiative low in cost
Implement the initiative/program in the current year
One of the main problems that plague minority communities is health issues. Racial and ethnic minorities bear a disproportionate burden of disease, injury premature death and disability in the U.S. These same dynamics are here in Nassau County in communities like Roosevelt Freeport, New Cassel, Hempstead and others. Among this population Diabetes strikes at 1.5 times the Nassau County average, and a recent study done by Nassau University Medical Center revealed that the obesity rate for children in the Freeport Roosevelt area was at almost 50%, much higher than the national level.
The Roosevelt community was selected to initiate "Recipes for Health" because the community is one of the selected target communities in Nassau County and has been described as a community of predominately non-Hispanic blacks and Hispanics who experience elevated morbidity and mortality from heart disease and diabetes yet are less likely to have access to healthful foods. In order to address the problems of Food Equity with tangible solutions, in 2010 Sustainable Long Island partnered with the Roosevelt Community Revitalization Group and the Long Island Farm Bureau to establish farmers’ markets in Roosevelt, and other communities, to bring fresh, nutritious foods to these communities, historically underserved by food retailers and markets.
In early 2014 The LHD's Bureau of Minority Health met with the Roosevelt Community Revitalization Group in order to plan how the LHD could enhance an already successful community farmers' market program. The Roosevelt Community Revitalization, (RCRG) is also joined with several agencies, Sustainable Long Island, Nassau County, Suffolk County United Veterans, The Town of Hempstead, Bethpage Federal Credit Union, Nassau University Medical Center now known as NuHealth, Long Island Farm Bureau, and others to continue address the issue of bringing healthy and affordable food to Roosevelt residents.
The Roosevelt Community Revitalization has a secured $15,000 budget to operate the Roosevelt Community Farmers' Market. They provided the LHD with an in-kind space at the weekly market as well as various produce to use in the recipes that were sampled. The LHD printed copies of the recipes to be distributed and provided materials from state and federal resources that were at no charge.
The goal of "Recipes for Health" is: To promote healthy eating with foods prepared with fresh ingredients.
The objectives are:
-To offer a recipe each week during the community Farmer's Market using the produce purchased at the Farmer's Market
- Make available a sampling of foods prepared in a manner other than what the population may be used too.
- Offer addition supportive materials regarding healthy eating and chronic disease management
The promotion of Healthy eating was provided at the community Farmer's Market whereby 30% - 50% patrons were engaged in the initiative. 23% of those engaged completed a survey. Numerous patrons (no actual data) including those engaged in the sampling took home supportive materials. Verbal feedback was also received from patrons who stated they enjoyed the recipes provided. Some said they made the recipe at home in the week following it's feature, and some verbalized their excitement regarding the upcoming recipes and samples. The factors that led to the success of the practice was the collaborative efforts of the health Department and the community Farmer's Market by providing individuals the needed tools, knowledge and skills in order to make healthier choices and prepare fresh ingredient recipes which reduce the intake of saturated and trans fats, cholesterol, added sugars, and sodium (salt). Every recipe uses at least one fresh, healthy, and nutritious ingredient so individuals learn to use whole foods in daily meal preparation and there are some healthy alternative substitutions for refined foods as well.
1,500 people attended the Farmers Markets during the 10 weeks in 2014. An average of 34% participated in the initiative. The survey was offered to farmer’s market patrons who approached the tent and tasted the featured recipe sample. 23% completed the survey. Only 6 respondents preferred the survey in Spanish translation, which was available. All others completed the survey in English.
A total of 74 surveys were completed over the course of 10 weeks. Samples were offered at five of the ten days the farmer’s market was open. A total of 1500 visitors attended the famers market over the course of the 9 weeks.
After patrons approached the tent, they were asked if they would like to complete a survey about their food choices as it relates to the recipe presented on that day. They were also given the option to have the surveyor record their responses for them as a significant number of patrons participated after purchasing their produce and had items in their hands already.
Table 1. Demographic Datan74Female (%)83.78Age (%) 21 & under 24.32%22-34 16.22%35-44 16.22%45-54 18.92%55-64 12.16%65 & over 10.81%decline 1.35%
Race/Ethnicity American Indian/Native American0Asian0Black/African American59.46Hispanic22.97White5.41Pacific Islander0Other5.41Black & Hispanic4.05
Of the respondents, 83.78% were female, the majority were aged 21 and under (21.32%) and identified themselves as black or African American (59.46%). A significant number of respondents were teens who worked at the farmers market. A copy of the recipe used to make the featured dish was made available to all patrons who approached the booth as well.
Table 2. Q1. In the last 30 days, how often have you used the featured fresh ingredient? (% responses)
A great deal 41.89
Quite a bit 18.92%Somewhat 18.92%Very little 5.41%Not at all 14.86%
First, respondents were asked if they have used to the featured ingredients in the last 30 days, then how likely they were to buy it before and after approaching the booth in order to determine if demonstrating a new recipe would influence their likelihood to buy the ingredient at the farmers market.
Table 3. Questions pertaining to perception of featured fresh ingredients before and after seeing demonstration (% responses). Not at all likelySlightly likelyModerately likelyVery likelyCompletely likelyQ2*6.769.4624.3228.3831.08Q31.352.7010.8140.5443.24Q42.702.705.4150.0039.19Q50.006.769.4635.1445.95*Pertains to participants reported perception prior to seeing the demonstration.
Table 4. Survey Legend for Questions Pertaining to Perception of Featured Fresh Ingredients Q1.In the last 30 days, how often have you used the featured fresh ingredient?Q2.Before seeing this demonstration, how likely were you to buy the featured fresh ingredient?Q3.How likely are you to buy the featured fresh ingredient after seeing this demonstration?Q4.How likely are you to recommend this recipe to a friend or family member?Q5.How likely are you to try this recipe at home?
Respondents overall were more likely to have used the featured fresh ingredient in the prior month (41.89%) and completely likely to buy it even before seeing the demonstration (31.08%). There was some increase in the likelihood to buy the featured fresh ingredient after seeing the demonstration as those who were very likely and completely likely increased to 40.54% and 43.24% respectively. Those who were not at all likely, slightly likely, and moderately likely all decreased. Half of respondents were very likely to recommend the recipe to a friend or family member while 45.95% were completely likely to try the recipe at home.
Since most respondents had already been using the featured fresh ingredients, this suggests that there is sample bias introduced as those likely to attend the farmer’s market are already likely to buy fresh vegetables. The questions pertaining to trying the recipe or recommending refer directly to the method of preparation of the ingredients which is also known to be an important factor in nutrition. Future surveys may assess patron’s perceptions of the method of preparation of such foods to get a more detailed view of how they eat. The recipes did use healthier alternatives and cooking methods however the survey’s main focus was on choosing foods that are more nutrition and less processed rather than how patrons chose to prepare them. Ultimately, there was still an increase in those who were likely to buy the ingredients after seeing the demonstration.
Surveying patrons before they purchased or viewed the produce may be a more accurate reflection of their perceived perceptions of food compared to after. Also, at that time, the patrons’ hands are not full and they may be more likely to participate as a result. A poll taken after the patrons saw the demonstration and shopped for their produce may indicate if they bought more of the featured ingredients. While causation may not be confirmed by this method an associated can be demonstrated.
Since a significant portion of the respondents were the teens working at the market, their responses often referred to the habits of their parents or income earners in their household. It may be helpful to determine if the respondents purchase the food for their household as this may influence their responses to the questions regarding perception.
The question about race and ethnicity may be more accurate if asked as two separate questions as some respondents identified themselves as black as well as Hispanic. An option to decline may also lead to more accurate responses as two respondents chose other but did not refer to themselves as another race or ethnicity, but simply as human. This question was combined to keep the survey to 1 page and therefore increase the likelihood that the respondents would participate.
Partner collaboration lesson learned and sustainability:
To improve healthy food access and utilization in Nassau County’s minority communities the Nassau County Department of Health (Bureau of Minority Health) partnered with the Roosevelt Community Revitalization Group in 2014 to implement "Recipes for Health" during a ten week timeframe. During the same timeframe, there were two other select communities, Westbury and Freeport, which also receives funding for farmers' markets and are also in partnership with Sustainable Long Island and the Long Island Farm Bureau. For the initial implementation of "Recipes for Health", the bureau decided to conduct the program at one of the three locations and choose the community of Roosevelt. The other locations heard about the program "Recipes for Health" and contacted the Bureau of Minority Health to request the program at their locations. Next season, 2015, we will conduct the program at all three locations by alternating locations. This will allow for greater access of the benefits of the program in other select areas in Nassau County. Additional data will be collected for a more comprehensive evaluation.
Practice lesson learned:
1,500 people attended the Farmers Markets during the 10 weeks with an average of 34% participating in the initiative. The program will evaluate as to what led to 1/3 participation as opposed to 50% or more. We will take a look at various factors including location of the tent at the market, and how staff introduced the imitative to the patrons. In addition, the program will be offered next season, 2015, to two additional communities and at that time more data will be collected with additional variables to analyze.
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