Emergency Food Programs: Untapped Opportunities for Extension?

Introduction

Emergency food programs such as food pantries and soup kitchens across the United States (US) have reported an increase in the demand for food (Nickels et al., 2009). Strikingly, the use of food pantries by households increased by 22% in 2008 compared to 2007, making food security an even more pressing issue in the US (Nord, Andrews, & Carlson, 2009).

Food security is defined as access by all household members at all times to enough food for an active, healthy life (Life Sciences Research Office & Anderson, 1990). At a minimum, food must be readily available, nutritionally adequate, safe, and acquired in socially acceptable ways (Life Sciences Research Office & Anderson, 1990). The United States Department of Agriculture currently refers to food insecurity as low or very low food security. In 2008, 17 million U.S. households (14.6%) were experiencing low or very low food security, an increase from 13 million (11.1%) in 2007(Nord et al., 2009).

With the recent economic downturn, combined with an increase in price of grocery store items, it is inevitable that many Americans will find food security harder to obtain (United States Department of Agriculture [USDA], 2011a). Many Americans may be faced with low food security for the first time in their lives and may not know how to eat a balanced meal with limited resources. Furthermore, individuals experiencing low or very low food security are more likely to use food pantries and emergency kitchens than individuals who are food secure (Nord et al., 2009).

Diet quality is also an important component of food security. Thus, while emergency food programs not only provide food, it is also important to consider opportunities to improve diet quality. Nutrition education is one strategy to improve diet quality of individuals who are experiencing low or very low food security. A study by Eicher-Miller, Mason, Abbott, McCabe, and Boushey (2009) revealed that nutrition education provided by the Supplemental Nutrition Assistance Education Program (SNAP-Ed) can significantly improve food insecurity of low-income adults. The American Dietetic Association "food insecurity" position paper also recognizes that nutrition education is an integral component of food security (Holben, 2010). However, the literature is limited as it relates to the nutrition education needs of emergency food program clients and even more so as it relates to nutrition education resource or training needs of emergency food workers (Joy et al., 1994).

Nutrition education within emergency food programs has traditionally been directed to clients and provided by Extension employees, including paraprofessionals of SNAP-Ed and the Expanded Food and Nutrition Education Program (EFNEP). However, outreach span and frequency can vary depending on state programming and budgets. Because emergency food program workers may receive questions from clients about nutrition, the objective of the study reported here was to determine what questions are most commonly being asked and how frequently. With an increased demand for emergency food, emergency food program workers are a possible channel to deliver nutrition-related information to the public and may need additional training and resources to do so.

Methods

Cognitive Interviews

A questionnaire to assess frequently asked nutrition-related questions by clients utilizing emergency food programs was originally developed with input from the Indiana Emergency Food Program Advisory Board, which includes Indiana food bank directors and emergency food program administrators. The draft survey was pilot tested using a cognitive interviewing "think aloud" technique (Willis, 2005) with emergency program workers (n=10) at eight different sites prior to the study. The results of the cognitive interviews were used to refine the current survey for the study.

Participants

Emergency food program addresses (n=796) were obtained from an on-line statewide database for emergency food assistance programs in Indiana. Programs included food pantries, soup kitchens, shelters, senior centers, and other locations that provide food to those with limited resources. One survey packet was mailed to each location containing an information sheet, survey, self-addressed stamped return envelope, and a calendar incentive (<$5 value). The information sheet instructed each program to identify one primary worker (paid or volunteer) who was at least 18 years of age, able to read English, and in current contact with clients, to complete and return the survey. Demographic information was also collected from respondents in the convenience sample to better understand the characteristics such as age, gender, and work history, in addition to best approaches to disseminate information to them if needed (Table 1).

The survey itself was comprised of questions related to the type of nutrition and/or food selection questions of clients, content of questions and perceived nutrition education needs of clients of emergency food programs (Table 2). A post card was mailed 1 month after the initial mailing to remind emergency food programs to complete the survey. The study was deemed exempt by the Purdue University Human Subjects Institutional Review Board. Descriptive statistical analysis was performed using SPSS (version 16.0, SPSS Inc., Chicago, IL, 2007).

Results

Of the 796 surveys mailed, 48 were returned from the post office because of "expired" addresses. Thus, of the 748 that reached their intended destination, 460 were returned, providing a 61.5% response rate. Demographic information on respondents is featured in Table 1. Most of the respondents (54.4%) were between the ages of 36 and 64 years, with more than one third (38.4%) ages 65 years or older. Most were also female (75.5%) and volunteers (59.6%), and worked for a food pantry (69.5%).

Survey question responses are summarized in Table 2. Over one-third (38.0%) of sites received nutrition-related questions from clients, with more than one-quarter (27.6%) receiving questions once or more per week. The most popular questions asked by clients of emergency food programs related to "what foods are best for a medical condition" (25.4%) and "how to cook or use the foods provided" (21.5%). Specific medical or dietary questions were mostly related to issues dealing with diabetes (26.5%) or heart disease concerns such as high cholesterol (16.3%) and high blood pressure (14.1%). When questioned, the majority (75.3%) of emergency food workers were interested in receiving nutrition information to give to clients. Single-page handouts (81.1%) were the most preferred format; however, most emergency food program sites had a computer (87.1%) with an Internet connection (74.5%), making electronic communication a possible delivery option to provide nutrition education resources to emergency food programs.

Table 1.
Participant Demographics and Emergency Food Program Site Characteristics

Respondent Demographics (n=460)	n (%)
Age (y)
18-35	33 (7.2)
36-64	248 (54.4)
65 years or older	175 (38.4)
Gender
Male	112 (24.5)
Female	346 (75.5)
Position
Volunteer	271 (59.6)
Paid	184 (40.4)
Length of "employment"
Less than 1 year	34 (7.4)
1-5 years	165 (36.1)
6-10 years	106 (23.2)
11 or more years	152 (33.3)
Frequency of "employment"
Less than once per month	4 (<1)
Once per month	29 (6.4)
1-2 times per month	58 (12.9)
Once per week	85 (18.8)
More than once per week	275 (61.0)
Characteristics of Emergency Food Program
Type of Program
Food pantry	316 (69.5)
Soup kitchen	41 (9.0)
Senior meal site	41 (9.0)
Shelter	22 (4.8)
Other	35 (7.7)
Computer available on site
No	128 (28.2)
Not Sure	7 (1.5)
Yes	319 (70.3)
Computer has Internet access
No	40 (12.9)
Yes	271 (87.1)

 

Table 2.
Participant Responses Regarding Nutrition Questions Asked at Emergency Food Programs

Question	Response n (%)
1. Do you receive questions about nutrition from people that receive food at this location?
No  [→You may skip to question #5]	280   (61.9)
Yes	172   (38.0)
2. How often do you receive questions about nutrition from people who receive food from this location?
Less than once per month	38   (22.4)
Once per month	33   (19.4)
2-3 times per month	52   (30.6)
Once per week	17   (10.0)
More than once per week	30   (17.6)
3. What type of questions do you receive about nutrition from people who receive food from this location? Check all that apply.
What foods are best to keep stocked at home	16 (3.5)
What foods are best for a healthy diet	70 (15.2)
What foods are best for a medical condition (such as diabetes)	117 (25.4)
What foods are best to eat for a special diet (such as vegetarian)	44 (9.6)
What foods interact with medications (such as grapefruit juice)	45 (9.8)
What foods are best for children	24 (5.2)
How to cook or use the foods provided	99 (21.5)
Food safety	21 (4.6)
Other	14 (3.0)
4. If you answered "What foods are best for a medical condition" OR "What foods are best for a special diet" in Question #3, what did people ask about? Check all that apply.
Diabetes	122 (26.5)
High blood pressure	65 (14.1)
High cholesterol	75 (16.3)
Gluten intolerance/ "Celiac Disease"/"Celiac Sprue"	9 (2.0)
Vegetarian diet	20 (4.3)
Other	13 (2.8)
5. Would you be interested in receiving nutrition information to give to people who receive food from your location?
No [→You are finished with the survey, thank you for your time!]	111 (24.7)
Yes	338 (75.3)
6. What type of nutrition information would you like to have for people who receive food from this location? Check all that apply.
What foods are best to keep stocked at home	157 (46.4)
What foods are best for a healthy diet	249 (73.6)
What foods are best for a medical condition (such as diabetes)	250 (74.0)
What foods are best to eat for a special diet (such as vegetarian)	105 (31.0)
What foods interact with medications (such as grapefruit juice)	189 (56.0)
What foods are best for children	160 (47.3)
How to cook or use the foods provided	213 (63.0)
About food safety	158 (46.7)
Other	19 (4.1)
7. What form of materials would be most helpful where you work? Check all that apply.
Posters	127 (37.6)
Brochures	187 (55.3)
Single page handouts	274 (81.1)
Recipes	231 (68.3)
Other	4 (0.8)
Percentages may not add up to 100 due to rounding. Total n may be less than 460 if respondent did not answer all questions.

Discussion

Although not the majority, more than one-third of emergency food program workers did report receiving nutrition questions from clients. While direct education efforts are available for emergency food program clients in some areas of the country through Extension, there is a lack of outreach directed towards the emergency food program workers themselves. In a follow-up study with emergency food program workers (n=66) from 15 different Indiana counties, frequency of training was assessed. Slightly more than half (52%) had reported receiving training, and of those, only 32 percent were required to receive the training. Furthermore, trainings were infrequent and, inconsistent and provided by multiple sources (Unpublished data).

Because workers at emergency food programs receiving USDA commodity foods are required to have at minimum one training per year, the lack of and gaps in training are concerning (USDA, 2011b). The need for additional training of food pantry staff regarding chronic disease and relationship to disease has been previously recognized (Greder, Garasky, & Klein, 2007). Diabetes as well as high blood cholesterol and blood pressure were dietary-related diseases of highest concern, which is similar to the findings of a previous study involving focus groups of community food pantry clients and consistent with our findings (Harmon, Grim, & Gromis, 2007).

It may be prudent to conduct training with emergency food workers similar to training for paraprofessional staff of EFNEP and SNAP-Ed to empower and educate emergency food program workers to provide nutrition information to their clients. Joy et al. surveyed both clients and workers of emergency food programs and recommended strategies such as training, community resource directories, and flyer inserts for food bags to assist workers (Joy et al., 1994). Training specifically targeted to workers of emergency food programs has been shown to significantly improve food safety-related knowledge and behaviors in a previous study of 276 food pantry, soup kitchen and emergency shelter workers in New York (Finch & Daniel, 2005).

Because recipes (Harmon et al., 2007; Joy et al., 1994; Rose, Cohen, & Laliberte-Carey, 1990) and recipe demonstrations (Keller-Olaman, Edwards, & Elliott, 2005) have been highly recommended and previously successful in emergency food program sites, it may be helpful to train emergency food program workers on how to demonstrate a recipe. Recipes remain as the most common requested item, often due to lack of knowledge of how to use commodity-type foods, but topics such as diet-related disease prevention and treatment, as well as food safety have also been commonly reported by other studies (Harmon et al., 2007; Keller-Olaman et al., 2005; Rose et al., 1990). If on-site recipe demonstrations are not an option, a mock "Food Network" for food pantries developed by the local Extension program could be played in the waiting room for clients to watch while they wait.

Conclusions, Implications, and Recommendations

While not all emergency food workers indicated nutrition education as a frequent inquiry, most were interested in receiving nutrition resources to distribute to clients. Many nutrition-related Extension programs that serve limited resource audiences currently provide outreach directly to clients. However, with limited budgets and looming cuts, it may become more difficult to have an ongoing presence in emergency food programs, and it could be more effective to directly train the workers on relevant nutrition topics. If SNAP-Ed and/or EFNEP staff are unable to directly train emergency food program workers because of income eligibility requirements, a partnership with family and consumer science or food safety Extension educators may be needed to develop and implement the trainings.

Yearly training is currently required for emergency food program workers at locations receiving commodity foods. With most sites having access to a computer and Internet, future efforts on this topic could explore using Web-based training and resources to provide nutrition information to emergency food program workers. Future research should determine the type of information and food availability changes needed at emergency food programs to make a significant impact on nutrition status and health and evaluation methods to measure outcomes.

References

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Finch, C., & Daniel, E. (2005). Food safety knowledge and behavior of emergency food relief organization workers: Effects of food safety training intervention. Journal of Environmental Health, 67(9), 30-34.

Greder, K., Garasky, S., & Klein, S. (2007). Research to action: A campus-community partnership to address health issues of the food insecure. Journal of Extension [On-line], 45(6 ), Article 6FEA4. Available at: https://www.joe.org/joe/2007december/a4.php

Harmon, A., Grim, B., & Gromis, J. (2007). Improving nutrition education newsletters for the Food Stamp eligible audience. Health Promotion Practice, 8(4), 394-402.

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Nickels, G., Kautz, E., Villaraigosa, A., Newsom, G., Stultz, J., & Cochran, T. (2009). Hunger and homelessness survey: A status report on hunger and homelessness in America's cities: The United States Conference of Mayors.

Nord, M., Andrews, M., & Carlson, S. (2009). Household food security in the United States, 2008: ERR-83, U.S. Dept of Agriculture, Econ. Res. Serv.

Rose, J., Cohen, N., & Laliberte-Carey, L. (1990). The role of a food bank in serving the nutrition education needs of food assistance programs. J Am Diet Assoc, 90(7), 988-989.

United States Department of Agriculture (2011a). Food CPI and expenditures: CPI for food forecasts. Retrieved from: http://www.ers.usda.gov/briefing/CPIfoodAndExpenditures/Data/cpiforecasts.htm   

USDA (2011b). Civil rights training requirements for volunteers. Food Distribution National Policy Memorandum (Policy No. FD-113). Retrieved from: http://www.fns.usda.gov/fdd/Policy/tefap_policies.htm 

Willis, G. (2005). Cognitive Interviews: A tool for improving questionnaire design. Thousand Oaks, CA: Sage Publications, Inc.