Abstract
Poverty is a complex problem in the United States with far-reaching consequences, often leading to a lack of food or lack of access to food. Proper nutrition and food intake are foundational to health and well-being. This participatory action research (PAR) project explored the challenges associated with living in poverty and managing food resources. Stakeholders engaged in a multiphase PAR process, which resulted in the development and implementation of a 7-wk occupation-based program. The program promotes graded learning of specific skills for managing food resources and emphasizes empowering each participant. Preliminary results indicate statistically significant improvements in participants’ ability to make meals with certain food items and in perceived satisfaction and performance in self-identified activities related to food resource management. These findings support the feasibility of the program and the need for participant-driven, occupation-based approaches to improving food security.
Poverty continues to be a persistent problem in the United States. Currently, 12.7% of adults and 18.0% of children live in poverty (Oliveira, 2018). It is a multidimensional problem, affecting people of all ages and creating complex barriers to health and well-being (Conroy, Sandel, & Zuckerman, 2010).
One of the most detrimental consequences of poverty is food insecurity, defined as a struggle to access, obtain, and manage food resources (Coleman-Jensen, Gregory, & Rabbitt, 2015). In 2014, 48.1 million people experienced food insecurity. Lack of consistent access to or intake of nutritional food leaves both individuals and families susceptible to health-related problems, including obesity, diabetes, asthma, congestive heart failure, cognitive impairments, depression and anxiety, and other stress-related illnesses (Chilton & Rose, 2009).
People living with food insecurity use many strategies to combat hunger, such as consuming spoiled food, imposing an involuntary dietary restriction, rationing food, or choosing inexpensive foods that contribute to poor nutrition (Kempson, Palmer Keenan, Sadani, Ridlen, & Scotto Rosato, 2002). These strategies create food safety and other risks to health. In 2014, the United States spent nearly 70 billion dollars on food assistance programs (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2015). Federally funded programs and local food pantries focus primarily on the provision of food. Despite this substantial budget, there has been only a marginal decline in the level of food insecurity.
Some communities have chosen to move beyond the traditional food pantry approach and develop additional programming. Martin, Wu, Wolff, Colantonio, and Grady (2013) implemented an innovative program that included a client choice food pantry, monthly individual counseling, and a referral process personalized to each program participant for additional services. Program results over a 1-yr period showed that participants in this program were less than half as likely to have very low food security. Gans et al. (2009) also reported that programming tailored to the individual is more effective than programs with a fixed curriculum. Initial findings from these programs, which include nutritional education and access to additional community resources, is encouraging (Gans et al., 2009; Martin, Shuckerow, O’Rourke, & Schmitz, 2012), but this programming still falls short in helping those struggling with food security identify and develop the skills needed to manage food resources effectively.
A paucity of research explores the actual needs of people living in poverty and struggling with food security. The lack of available programming to address those needs is also evident. This gap in the literature, as well as the need to address food insecurity, prompted a participatory action research (PAR) project in a community in the Midwest. A group of stakeholders formed with the intent of developing a program to address the needs within the community.
PAR is designed to address a social problem and build capacity within a community (Hacker, 2013). It is founded on the principle that people who experience a certain phenomenon should be an integral part of investigating that phenomenon (Taylor, Suarez-Balcazar, Forsyth, & Kielhofner, 2006). The approach involves innovating and experimenting to generate or modify services and study how those services work. The PAR process is ongoing and reflective in nature.
The stakeholders in this PAR project include people living in poverty and struggling with food security, staff at a local agency whose mission is to eliminate poverty in the county, occupational therapists, and a United Way Halt Hunger Initiative representative. This project has been ongoing for more than 3 yr, and Phase 5 (program implementation) was recently completed. Previous phases included collecting data regarding the needs, skills, and current resources of people living in poverty and struggling with food security; trialing a sample program session; and piloting the program. Phases of reflection were also interspersed within the project. All phases of the project received institutional review board approval before implementation.
Focus groups were used to gain insight into the strengths and limitations of the developing program, address concerns, and gather information about participant perceptions of the process. This plan, act, review, and reflect cycle of PAR propelled the project forward.
The first four phases of the program were instrumental in helping the stakeholders generate a more cohesive picture of the needs of the people living in poverty and struggling with food security. Participants reported limited, if any, opportunities to develop skills for managing food resources, such as effectively reading a recipe, storing food, and planning meals. They also discussed using faulty kitchen utensils, which made meal preparation tedious and difficult. The added challenge of using faulty utensils or equipment often caused the food to be unsatisfactory and decreased confidence associated with cooking.
As the PAR process unfolded, it became evident that current programming, while helpful, did not address the habits, routines, and skills required to manage available food resources effectively or the strategies needed to adapt to the fluctuating circumstances common to people living in poverty. It also became apparent that the limited ability to manage food resources not only affected food security but also detracted from people’s ability to move beyond the focus of meeting immediate needs. The stress-inducing challenges for people living in poverty and struggling to obtain and maintain food security are well documented in the literature and often include being forced to choose between food and other vital necessities such as health care (Knowles, Rabinowich, Ettinger de Cuba, Cutts, & Chilton, 2015).
The first four phases of this PAR project contributed to the development of Living Better With What You Have, an occupation-based program designed to empower people living in poverty to explore, examine, create, and develop skills for managing food resources. Additionally, participants are encouraged to take risks in a supportive environment and reflect upon those actions and their results. Implementation of the program sought to determine whether an occupation-based program could help people living in poverty maximize their food resources and empower them to live better with what they have.
Living Better With What You Have
Program Philosophy and Goals
The Model of Human Occupation (MOHO) is a holistic model that considers multiple factors that influence a person’s occupational performance (Kielhofner, 2008). The model proposes that people are composed of dynamic interacting elements: volition, habituation, and performance capacity. These elements work together within a particular environment to influence the formation of a person’s occupational identity and affect his or her occupational performance (Forsythe et al., 2014). MOHO not only served as a useful framework to explain the role of occupational therapy to other stakeholders but also helped guide the creation of program goals and modules.
PAR stakeholders embraced the assumption that engagement in a meaningful task could help develop skills, build confidence, establish habits, and increase occupational performance. Program goals included
Examining current values and interests regarding managing food resources,
Exploring skills and resources that could decrease food insecurity or the susceptibility to becoming food insecure,
Identifying and developing skills to manage available food resources or obtain additional food resources,
Enabling the practice of learned skills within the participant’s natural context to encourage the transfer of skills and abilities,
Empowering each participant to guide his or her progress within the program and contribute to the growth of others, and
Enhancing the community by embracing a collaborative approach to program implementation.
A module template was created to help organize the program. This template includes a brief description of the module, objectives, theoretical connection, level of difficulty, prerequisite knowledge and skill, vocabulary and terms, incentives, and module specifics (room set-up, equipment, tools, groceries). Multiple modules are layered to build a session. Many modules have been developed, and new ones are created each time the program is conducted to meet the differing needs of the participants. Table1 outlines a sample session and its modules.
Session Outline Example
Program Description
The program consists of seven 2.5- to 3-hr sessions. Each session begins with the participants sharing stories of accomplishment or trial and error regarding their goals from the previous week. After the group processes the shared stories, participants move into a didactic component, which addresses a topic and skill focused on managing food resources as identified by the participants. After the didactic component, the participants move to a kitchen setting and engage in a task that either directly applies the information just learned (e.g., measuring portions) or contributes to the larger focus of managing food resources (deboning a chicken to store the leftovers, creating meals that use ingredients that spoil quickly). This experiential component allows participants to explore and develop the skills needed to be intentional with a limited amount of food. The tasks are strategically chosen and graded by the occupational therapist to build on the participants’ knowledge and skills targeted in previous sessions or to challenge the development of new or emerging skills. This part of the session can also reinforce developing habits such as safe food handling techniques.
All participants and facilitators then assemble at a communal table to taste and share the prepared food. During this time, participants share their thoughts about the various aspects of the tasks. The discussion is semistructured and designed to help participants examine the session experience and link it to their personal goals. Facilitators ask strategic questions that prompt the participants to explore specific aspects of the session. For example, the participants may be asked to anticipate the challenges of replicating the experience in their own home. This question can generate conversations that explore solutions unique to each participant. Additionally, this reflective component can challenge beliefs about food or food-related skills (e.g., “I don’t like vegetables” or “I can’t make eggs that taste good”). The facilitators end the discussion by connecting the completed tasks to goal achievement and helping participants identify that next step toward their ultimate goals.
Topics emerging from this dialogue aid in determining the content modules for the next session. Examples of topics that have emerged from this dialogue include effectively using flour and strategically purchasing and using spices. It is through this guided reflection that the participants construct personal meaning from the experience, linking it to previous learning and future experiences. Upon session completion, each participant receives a minimum of one incentive—typically, a kitchen tool that can be used at home—to continue integrating newly acquired skills with established meal preparation habits and routines. Sessions that contain assessment and measurement require some modification to this format.
Method
Design
A PAR approach was used to guide this project. Before the program implementation phase, the program was piloted with 6 participants, 4 of whom completed the program. During the program implementation phase (18 mo), the 7-wk program was offered 4 times. One session was cancelled because of low enrollment. The number of participants per program ranged from 4 to 6. Program capacity was capped at 6 participants because of space limitations.
Setting and Participants
This research occurred on a university campus in an occupational therapy lab equipped with a kitchen. Participants were chosen from a convenience sample. A local agency that works with people living in poverty recruited all study participants through flyers and social media platforms. Participants were candidates for the study if they participated in or had graduated from a national Bridges Out of Poverty Getting Ahead program. Participants were excluded if they were actively engaged in a community-based program focused on nutrition or cooking.
Instruments
Two instruments were used to guide the occupation-based intervention. The Food Security Scale, developed by the U.S. Department of Agriculture (USDA), provides ordinal data that reflect the frequency and severity of food security (Bickel, Nord, Price, Hamilton, & Cook, 2000). An 18-question survey was used to determine a status-level category ranging from food secure to food insecure to food insecure with hunger–severe. This scale was used to obtain information about the participants’ current level of food security, as defined by the USDA. This scale has been used nationally to document food insecurity.
The Individual Food Resource Profile (IFRP) is an instrument designed by this team to gather information from participants regarding the number of people living in the home, current or past use of community resources, availability of common kitchen items, and reasons for attending the program. Data about participants’ current habits and routines and skill level for managing food resources were also collected. The IFRP contains questions about specific dietary preferences and restrictions. This information is used to assist in individual goal setting, determine session content, and identify the incentives (kitchen tools, ingredients) that may be needed for the participants to practice the skills in their natural environment.
Living Better With What You Have outcome measures include the Canadian Occupational Performance Measure (COPM; Law et al., 2005) and the Making Meals Performance Measure (MMPM; Schmelzer & Leto, 2016). The COPM was designed as a client-centered, semistructured interview used to identify issues of personal importance to a client and to detect change in a client’s self-perception of occupational performance over time (Law et al., 2005). The COPM was used in its standardized format during the piloting of the program. Feedback from participants, as well as reflective thoughts from the occupational therapists, indicated that the participants wanted to be more actively involved during the assessment. Based on this feedback, a complementary COPM form was created. This form allowed participants to document issues in various areas of occupation and promoted careful consideration of these issues in relation to their occupational performance. The form also contained the COPM rating scales so each participant could become familiar with and visualize the scale throughout the process. This modification encouraged increased participant engagement and also helped with goal setting.
The administration of the COPM began with an explanation of the assessment and its purpose in a group format. The group then discussed some of the challenges they experience in areas of occupation and took notes on the additional COPM form provided. After the group conversation, a one-on-one discussion between a facilitator and a participant occurred to help the participant delve deeper into the issues that were the biggest challenges to his or her current occupational performance. The participant then determined the level of importance for the identified issues and provided a score for performance and satisfaction. This modification capitalized on the principles of PAR and led to an increase in the rapport between facilitators and participants and among the participants themselves.
The MMPM was created for this program as a mechanism for measuring change in a participant’s skill in making meals. The purpose of this assessment is to measure the participant’s ability to plan meals from a list of available food items. The MMPM is designed to specifically measure the performance capacity of the participant and assess his or her ability to maximize the use of listed food items to create as many meals as possible within a given time frame. The food item and the amount of food used are documented. Data points retrieved include number of meals created, number of food items used, and percentage of overall food units used. A complexity score can also be calculated. The interrater reliability of the MMPM is excellent, ranging from 0.979 for number of meals to 1.00 for number of food units. Additional psychometric testing of this measure is under way.
Procedures
The USDA Food Security Scale, IFRP, and MMPM were administered during Session 1. The COPM was administered in Session 2 to ensure enough time was available to complete the semistructured interview with each participant. The MMPM and COPM were readministered in Session 7.
Data Analysis
Outcome data were analyzed using IBM SPSS Statistics (Version 23; IBM Corp., Armonk, NY). Paired t tests were used to calculate change in the continuous variables (MMPM), and Wilcoxon signed-rank tests were used to note changes in categorical data (COPM). Effect sizes were also calculated because a small sample size affects the power to detect change. Cohen’s (1988) criteria for effect size were used: small effect = 0–0.29, medium effect = 0.30–0.49, and large effect = 0.5–1.0.
Results
During Phase 2, stakeholders voiced concerns regarding the collection of demographic information, stating that it felt too intrusive. Demographic data collection was limited because of this concern and the desire to stay true to the principles of PAR. Sixteen participants started the program, and all 16 finished. Table 2 lists demographic data, including the findings from the Food Security Scale. Results of the COPM (Table 3) showed that participants demonstrated a statistically significant change in both perceived satisfaction and perceived performance from baseline to end of program (p ≤ .05). Additionally, on an individual level, all 16 participants demonstrated an increase of ≤2 points in both perceived satisfaction and performance. According to the creators of the COPM, a change of at least 2 points constitutes clinical significance (Law et al., 2005).
Participant Characteristics
Note. M = mean; SD = standard deviation.
Food Security Scale findings.
Comparison of Baseline and Program Completion Values for Outcome Measures
Note. COPM = Canadian Occupational Performance Measure; M = mean; MMPM = Making Meals Performance Measure; SD = standard deviation.
The occupational performance issues identified by the participants during the in-depth COPM semistructured interviews captured the complexity involved in maximizing food resources. Examples of such issues include menu planning, strategic shopping, using and storing leftovers, the development of specific cooking skills, increasing understanding of nutrition or dietary restrictions, and improving problem solving or organizational skills associated with managing food resources. Some participants also focused on enhancing healthy and stable eating habits within the family.
Participants also demonstrated a statistically significant change in the number of meals they were able to create, t(15) = 4.162, p = .001, measured with the MMPM (see Table 3). Additionally, data revealed a large effect size (d = 0.855). Aggregated data analysis of the number of food items used and the percentage of food items used did not reach levels of significance. However, further analysis of these data points on an individual level helped triangulate personal growth and speaks to the individualized nature of maximizing food resources. For example, Sabrina (a pseudonym), recently diagnosed with multiple food allergies, identified a lack of understanding about her dietary restrictions as a problem during the COPM. At baseline, Sabrina created 10 meals using 19 different food items and 31% of the overall food available. Upon program completion, she created 14 meals but was able to do so while following her dietary restrictions as evidenced by using only 10 approved food items while still increasing the overall percentage of food used to 38%.
Discussion
Food insecurity does not simply equate to an individual being hungry and the physical discomfort and nutritional loss associated with decreased food intake. It also manifests itself in psychological ways because people who are food insecure have to constantly worry about how they will obtain food (Martin et al., 2012). This emotional stress is heightened when a person has to care and provide for children (McCurdy, Gorman, & Metallinos-Katsaras, 2010). People who are food insecure often lack the funds necessary to purchase an adequate amount of food and therefore turn to food pantries, government assistance programs, or both to supplement their needs (Martin et al., 2012).
The largest federally funded program that helps individuals and families obtain food, the Supplemental Nutrition Assistance Program (SNAP), has been criticized for not reducing food-related hardship; however, many still support its effectiveness in reducing hunger (Ratcliffe, McKernan, & Zhang, 2011). The criticism surrounding the federal programs that simply provide food has prompted a shift toward developing and implementing nutrition education programs that can be used in conjunction with SNAP to combat food insecurity (Dollahite, Pijai, Scott-Pierce, Parker, & Trochim, 2014). This shift acknowledges that people who lack the funds for food may also lack knowledge and skills, which if learned, could help decrease food insecurity.
Another federal program, the Expanded Food and Nutrition Education Program, has developed a community-based nutrition education program for low-income parents. Its curriculum, called Eating Right Is Basic–Enhanced, focuses on nutrition education and targets change in four behavioral constructs (diet quality, food safety, food security, food resource management). Likewise, Freshplace is an innovative food pantry in Hartford, CT, that offers an intervention based on the Stages of Change Model in the hopes of addressing the underlying causes of poverty and food insecurity (Martin et al., 2012). The creation of, and funding for, programs such as these, which target knowledge and skill development associated with managing food resources, is encouraging because it points to a recognition that there are multifaceted contributors to hunger. These programs are demonstrating success and changing the conversation about hunger.
People living in poverty, especially those who grew up in poverty, are often deprived of opportunities to engage in the crucial occupations needed to develop healthy lifestyles. Living Better With What You Have deployed an occupation-based approach to developing the skills and habits participants identified as hindering their ability to successfully manage their food resources and attain and then sustain food security. IFRP data revealed that 50% of the participants always or most of the time did not know what to do with the foods they received from food pantries. Examples of foods that presented challenges included dried beans, whole chickens, and “mystery meat.” Sixty-nine percent of the food recipients did not know how to use leftovers to create another meal, and 38% reported being on a special diet but not understanding how that translated to daily decisions regarding food intake and health. These participants were trying to use their available resources as strategically as possible to avoid being hungry but were limited in the skills needed to maximize their food resources.
Engagement in occupations such as planning meals, following or adapting recipes, preparing food, and budgeting for food was used as a means to become more confident and proficient in skills that could help decrease food insecurity. A relationship between food preparation with basic ingredients and food security is noted in the literature. Engler-Stringer, Stringer, and Haines (2011) reported that low-income women who prepared foods using basic ingredients at least 3 times per week were more than twice as likely to be food secure than those who did not. The statistically significant changes in both the MMPM and COPM data, as well as the large effect size, support both a focus on the development of basic food prep skills and the power of using occupations as a means to improve a person’s ability to manage food resources more effectively. It is also suspected that these significant changes support the notion that people living in poverty are often deprived of opportunities to explore and engage in the development of basic life skills that contribute to health and quality of life.
The repeated opportunities to explore new foods and recipes and to develop emerging skills in a supportive environment helped unlock potential the participants did not know they possessed. The increased energy, which often accompanies the little successes associated with learning, was reinvested in their skill development. The interdependent relationship among skill development, habituation, and volition (Kielhofner, 2008) was evident and emerged as a result of the program design and participant engagement.
The distinct principles that guide occupation-based interventions set this program apart from other innovative programs that teach nutrition or offer cooking classes. In addition, this PAR project exposed how living in poverty imposed limitations on engagement in necessary activities of daily living. The participants possessed a strong desire to learn what many in society would consider to be basic skills. They eagerly engaged in opportunities to problem solve, take little risks, and explore their desires to build on skills and develop competence. Exclusion from engagement in necessary or meaningful activities because of external factors is identified as occupational deprivation in the literature (Whiteford, 2010). Research exploring the consequences of occupational deprivation has been conducted but is limited in scope (e.g., Crawford, Turpin, Nayar, Steel, & Durand, 2016; Suleman & Whiteford, 2013; Wells, 2015). The results of this study demonstrate that an occupation-based program can help people living in poverty maximize their food resources, but perhaps more importantly, the overall PAR project has illuminated the significant challenges that face people living in poverty and the factors that contribute to these challenges. Additional research in this area is greatly needed.
Study Limitations
PAR is a challenging approach and requires that researchers seek input from and listen to stakeholders about aspects of the research process (Luborsky & Lysack, 2006). This collaboration distinguishes PAR from other approaches, but the strong rapport needed for effective collaboration takes time to develop. The collection of demographic information and the number of outcome measures chosen for this study were limited because of stakeholder concerns. These concerns will be revisited in the next reflective phase of the PAR process with the hope of exploring measures of self-efficacy and quality of life. Additional measures could help further define the program’s impact.
The small sample size for this study was also a limitation. Future research needs to focus on increasing the frequency of the program or exploring the use of larger groups and then comparing the results to a control group. The use of the COPM for this focused program could be questioned because the modifications made to the COPM may have affected its established psychometric properties. However, the creators of the COPM noted that “it is not necessary for clients to identify problems in all areas of occupational performance” and that “the categories are somewhat arbitrary” (Law et al., 2005, p. 14). Additionally, they suggested that “therapists should develop a process or style of administration that is comfortable for them and their clients” (Law et al., 2005, p. 14). Finally, the psychometric properties of the MMPM are in the process of being established.
Implications for Occupational Therapy Practice
This is the first study to explore the effectiveness of an occupation-based program focused on increasing participants’ abilities to manage food resources effectively. People living in poverty often have underdeveloped capacities that are overlooked during program development and resource allocation. Therefore, the implications for occupational therapy practice are as follows:
The negative consequences of occupational deprivation for people growing up and living in poverty need to be further explored and examined.
Programming that considers context and targets volition, habituation, and skill development in occupations helps address the underlying causes of food insecurity and highlights the distinct value of occupational therapy.
Results can be used to promote partnerships with community agencies such as homeless shelters and community mental health centers to facilitate programming that promotes graded engagement in instrumental activities of daily living skills for people living in poverty.
Conclusion
This PAR project emerged from community concerns about how to help people living in poverty manage their food resources more effectively and combat food insecurity. Current findings support the feasibility and positive impact of developing and implementing an occupation-based program to address these concerns using a participatory action approach. Continued engagement in the PAR process is needed to determine whether these findings are maintained over time and whether the changes noted by the participants translate to sustained food security. Additionally, this project exposed the need for occupational therapy practitioners to explore the consequences of occupational deprivation for people living in poverty. Limited opportunities to engage in basic occupations, specifically associated with food resource management, have far-reaching implications for a person’s health and well-being.
Acknowledgments
We thank the Hope House for collaborating on this important project and the Hancock County United Way Halt Hunger Initiative for its financial support. We also thank the many students from the University of Findlay’s Occupational Therapy Program for their passion and dedication throughout the multiple phases of this project. Finally, we want to thank all the participants for truly embracing the PAR process.