Changing the Conversation About Hunger: The Process of Developing Freshplace
Despite public and private food assistance programs, food insecurity and hunger are persistent public health problems. Freshplace is an innovative food pantry collaborative whose goal is to build long-term food security and self-sufficiency among residents of the North End of Hartford, Connecticut. Freshplace was founded by Foodshare (FS), the Chrysalis Center (CC), Inc., and the Junior League of Hartford (JLH), Inc., who then partnered with the University of Connecticut to design and evaluate the program.
Objectives: This article describes the community-based participatory research process involved with developing and evaluating Freshplace.
Methods: We are conducting a randomized, controlled study to compare 100 Freshplace members with 100 people who receive food from traditional food pantries. Main outcome measures include food security, self-sufficiency, and diet quality. Change scores are compared from baseline to 3 months using independent t tests.
Results: Freshplace opened in July 2010. We have recruited 233 people to participate in the study. Over 3 months, Freshplace members had larger change scores than the comparison group in food security scores (1.6 vs. 0.7 points; p < .01), and fruit and vegetable intake (1.9 vs. –1.4 points; p < .01).
Conclusions: Freshplace is a successful, community– university partnership bringing together three community agencies and a state university. This is the first food pantry intervention to be evaluated, and preliminary results are promising.
Nutrition, community health partnerships, community-based participatory research, community health research, healthy people programs, health promotion, poverty
Hunger and food insecurity are persistent public health problems in the United States with long-lasting social and health implications. Whereas hunger is the physical sensation of not having enough food, food insecurity is defined as limited availability of nutritionally adequate and safe foods or limited ability to acquire acceptable foods in socially acceptable ways.1 Food insecurity manifests itself in families worrying about and coping with limited food supplies because they do not have money to buy more. In 2010, 14.5% of all U.S. households struggled with food insecurity at some point in the year.2 Food insecurity has been linked with depression in adults,3,4 and poor developmental indicators in children,5 such as limited academic performance.6
Primarily in the late 1970s and early 1980s, private charitable groups and faith-based organizations created “emergency” food assistance programs to supplement government programs and to address the growing problem of hunger. These charitable programs include foodbanks that warehouse and then distribute food to food pantries, community kitchens, and shelters. These programs have grown exponentially in size and number. FS, the regional foodbank of greater Hartford, Connecticut, is a classic example of this expansion. Founded in 1982, FS served 23 agencies in 1983, and now works with a network of 300 local food pantries, community kitchens, and [End Page 429] shelters serving persons in need.
Despite the growth in pantries, there is a paucity of research documenting their ability to increase food security or improve health outcomes associated with food insecurity. In essence, there has been a 30-year intervention with no evaluation.
Freshplace is an innovative food pantry that was founded by three community agencies—FS, the CC, Inc., and the JLH, Inc.—to build long-term food security and self-sufficiency among residents of the North End of Hartford, Connecticut. Self-sufficiency is often defined broadly as holding a paying job or being in a state of well-being, with limited reliance on welfare benefits.7 The goal of Freshplace is to provide a more fundamental approach to the problem of food insecurity by addressing the root causes of poverty. After collaborating for 3 years, these organizations then formed a community– university partnership with the University of Connecticut to evaluate the program. To our knowledge, this is the first study to measure outcomes from a food pantry intervention. In this paper we describe the community-based participatory research process involved with developing and evaluating Freshplace. We describe early results, lessons learned, and next phases for the project.
The mission of FS is to work to end hunger as a part of the overall community effort to alleviate poverty in greater Hartford. FS recognizes that, to address hunger, programs must go beyond direct food distribution to address the underlying issues of poverty and food insecurity. In 2004, FS started developing the idea of a new type of food pantry and sought a community partner to help with the initiative.
The CC is a private, nonprofit, healthcare agency that provides community support services to people who struggle with psychiatric disabilities, substance abuse, HIV/AIDS, release from incarceration, and homelessness, and who live substantially below the poverty line. In 2005, FS asked CC to partner on a new initiative that would build self-sufficiency among members as a way to provide long-term help to those in need. These organizations submitted a proposal to the JLH through the League’s New Project Development proposal process.
The JLH is a women’s educational and charitable organization whose members are committed to promoting volunteerism, developing the potential of women, and improving communities through the effective action and leadership of trained volunteers. Every few years, the JLH membership chooses a project in which to invest time and resources, and to help the project become self-sustaining. JLH chose the proposal from FS and CC to focus their efforts for the next few years. There was a fortunate synergy of efforts that coalesced between these three community agencies (CC, FS, and JLH) during the early stages of this work with a similar goal of developing Freshplace.
A Steering Committee was formed with representation from all three agencies, comprised of approximately 10 people. The three community partners held regular Steering Committee meetings from 2006 on a monthly basis. Discussions included defining the mission and goals for the project, deciding on a name and logo, determining who would be served and how often, the layout of the food pantry, and what services and programs would be offered. Although the process of developing Freshplace over the course of several years was longer than most committee members first envisioned, many committee members now reflect on how the thoughtful, lengthy timeframe helped with the success of launching the new program.
The three founding agencies agreed on the different roles and contributions each would make to facilitate the long-term sustainability of the project. CC would serve as the fiduciary agent and would house Freshplace in their facility. FS would provide food, 90% of which would be fresh fruits, vegetables, dairy, and meats, for the first 3 years. JLH would provide operational funding and volunteer support for two 3-year commitments. People who are served by Freshplace are called “members” rather than clients.
In the spring of 2009, the Steering Committee asked a program evaluator from the University of Connecticut to conduct a needs assessment for the neighborhood surrounding Freshplace, to identify sociodemographic poverty data.8 Only 51% of the population in the Freshplace census tract were employed. Thirty-two percent of families and 34% of children had incomes below the poverty level. Formative research was [End Page 430] also conducted using focus groups with area food pantries to identify their perceptions of food needs in the community.
During the planning phase in the summer of 2009, one of the authors (KM), who has over 10 years of experience in food security research, approached the Steering Committee and proposed a community–university partnership to assist with the design and evaluation of Freshplace. The Steering Committee recognized and supported the need for evaluating the project, and a community–university partnership was formed. Over the course of several months, discussions involved how to recruit participants, who would serve as a comparison group, how to ensure buy-in and acceptance from the local community, and fundraising for operating costs. The Steering Committee agreed that the evaluation and research data would help to drive the future development of the project.
The emphasis of the Freshplace program is to help individuals set small, achievable goals for behavior change that, when accomplished, will boost their confidence in coping with similar problems in the future. We recognize that helping people to make these behavior changes is a process that involves stages. The intervention is based on the Stages of Change Model.9 To help members achieve improved outcomes in food security and self-sufficiency, it is important to understand which stage they are in so we can tailor information, programs, and services that are most beneficial to them. Programs that match services and information with the appropriate stage of readiness are more effective and more sustainable than programs that apply a “one-size-fits-all” approach. This theoretical framework will help to ground the intervention and facilitate replication by others.
We are conducting a randomized, controlled group study with quarterly follow-up measurements for 18 months. Study recruitment began in June 2010, and Freshplace opened in July 2010.
One of the key decisions of the Steering Committee was determining who would be eligible for and how to recruit members to Freshplace. By simply opening the doors and advertising a new type of program, there was concern about selection bias and that people choosing to come would be more food secure or self-sufficient than typical food pantry clients. The committee decided to recruit study participants from local food pantries and randomize them into the Freshplace intervention or to serve as a comparison group at the food pantry. KM, the study Principal Investigator, discussed the Freshplace program and the research study with local food pantry staff and asked their permission to recruit study participants from their pantries. We received written permission from these pantries to recruit in their sites.
The Freshplace Steering Committee set a goal of serving 100 families by the end of the first year, staggered to add 25 participants each quarter. To be eligible, study participants must be 18 years or older and live within the three zip codes representing the North End of Hartford. All study participants receive incentives of $10 upon recruitment and baseline collection, $5 for quarterly collections, and $10 for follow-up data collection at 12 months. The study protocol was approved by the University of Connecticut Health Center Institutional Review Board.
When people are waiting in line to receive food at the pantries used for recruitment, trained research assistants explain that they work at the University of Connecticut and are recruiting people to be part of a study to see how food pantries help people get enough food. After consenting to be part of the study, and after completing a baseline survey, participants help to choose whether they will be randomly assigned to either the Freshplace intervention or the Food Pantry comparison group. We use an opaque bag containing two balls, a blue ball signifying the comparison group and a red ball signifying Freshplace. Participants pick a ball randomly from the bag. We believe this process helps participants feel more empowered than if they were simply assigned to a group.
The Freshplace intervention includes fresh food, case management, and services and referrals. Freshplace members can select food at the Freshplace pantry twice per month. Freshplace is designed as a client choice pantry where members choose their own food such as they would at a grocery [End Page 431] store, rather than having bags of food prepackaged for them by pantry staff, which typically occurs in traditional food pantries. Client choice pantries help to instill dignity and recognize personal and cultural preferences among food pantry participants.
The Freshplace intervention also includes individualized case management. All members meet monthly with a project manager to develop a Freshstart Plan to identify and monitor their goals for becoming food secure and self-sufficient. During the initial session, the member and project manager discuss goals, expectations and potential barriers for becoming food secure and self-sufficient. This involves developing concrete target behaviors with small achievable goals to achieve by the next month (such as receiving nutrition education, attending GED classes, and applying for Supplemental Nutrition Assistance/food stamps). The project manager uses motivational interviewing techniques to reinforce positive behavior and provides one-on-one social support.
To help members meet their Freshstart goals, the Freshplace intervention also offers an array of services and referrals tailored to the individual needs of each member. For example, members can participate in a 6-week cooking class, use computers to search for jobs and work on resumes, and consult with dieticians, who provide nutrition education on site. The project manager also makes referrals for public assistance programs such as Supplemental Nutrition Assistance and energy assistance.
The survey instrument includes measures for food security, self-sufficiency, diet quality, and household demographics. [End Page 432] Household food security is measured using the validated USDA Food Security Module. The module consists of 10 questions for households without children and an additional 8 questions for households with children. The questions ask with increasing severity about a household’s experiences with food insufficiency, and scores are scaled from 0 to 10.2 Self-sufficiency is measured using the Missouri Community Action Family Self-Sufficiency Scale which includes 10 scales, including levels of education, employment, income, and housing, with scores that range from 1 to 100.10 Diet quality is measured using the Block Food Frequency Screener for typical consumption of fruits, vegetables, and fiber foods during the previous month.11
Data were analyzed using SPSS (v 18.0; SPSS, Inc., Chicago, IL). Bivariate analyses were conducted to examine differences between Freshplace and comparison groups using Spearman correlations and chi-square tests. To compare changes over time, change scores were calculated by subtracting baseline scores from 3 month scores. Differences in change scores between Freshplace and the comparison group were assessed using independent t-tests.
From June 2010 to June 2011, 233 study participants were recruited to participate in the study, including 118 who were randomized to the comparison group and continue to receive food at traditional food pantries. Among the 115 participants who were randomized into Freshplace, 100 (87%) have shown up to Freshplace to receive services. Women were significantly more likely than men to show up for initial services (χ2; p < .01).
A description of our study participants is listed in Table 1. The majority of study participants are Black, single women. Average age of participants is 51 years. The only significant difference between Freshplace members and the comparison group at baseline is that Freshplace members tend to go to food pantries less frequently than the comparison group (56% vs. 70% going at least once per week; χ2 test, p = .03). One quarter of participants (26%) have a household member with diabetes and two thirds (66%) have a family member with high blood pressure. The vast majority of participants are overweight or obese (70%) and food insecure (85%).
Changes over 3 months are listed in Table 2. We found a significant difference in changes in food security scores over time, with Freshplace members gaining an average of 1.64 points compared with the Comparison group, which gained an average of 0.65 points (p = .01). Changes in self-sufficiency scores over 3 months approached significance (p = .08; Freshplace members gained 2.4 points on the self-sufficiency scale compared with the Comparison group, which lost an average of 0.38 points). There was also a significant difference in changes in fruit and vegetable scores, with Freshplace members gaining an average of 1.9 points over time compared with the Comparison group, which lost an average of 1.4 points (p < .01).
This is the first study to evaluate a food pantry intervention and early results are promising. This is highly innovative and [End Page 433] may serve as a model for replication in other communities. The next phases of the project involve determining what outcomes and benchmarks are necessary for members to successfully graduate from Freshplace. Also, if members are not actively working toward their goals, at what point will they be “discharged” to make room for additional members? Another key consideration is how to identify and document the key components of the intervention that should be replicated by others. For example, can this project be replicated in other communities, among different ethnic groups, and in different settings? The Steering Committee held a retreat in June 2011 to discuss these questions and plan for the next year of the program.
There are some study limitations that should be taken into consideration. Participants are recruited from two food pantries in one urban area that is predominantly Black/West Indian with high poverty rates. Therefore, we may not be able to strictly generalize findings to other communities or other food pantries. However, these pantries reflect “typical” food pantries that are found in communities nationwide, serving low-income households in need. We believe these findings may provide practical information that can be useful for other communities.
Although food pantries were initially started as “emergency food programs” to address an acute food need, the longevity and growth of food pantries represents an institutionalization of these programs as a response to hunger. Some would argue that the role of food pantries is not to provide long-term aid, but when the “emergency” has lasted for more than three decades, it is time to examine the impact of these programs. The evaluation of Freshplace is an important step in this direction.
The Freshplace community–university partners recognize that it takes more than food to end hunger—it requires addressing the many underlying issues of poverty that impact a family’s ability to access enough food. Freshplace is changing the conversation about hunger from simply providing food to providing case management, referrals, and linkages to other programs to address the multifaceted causes of hunger. We mark the 1-year anniversary of Freshplace with promising results, strong partnerships that have lasted several years, and a thoughtful eye toward year 2.
Freshplace programming could not have been possible without the generous funding of the United Way of Central and Northeastern Connecticut. Funding for the research is generously provided by the Connecticut Institute for Clinical and Translational Science at the University of Connecticut, and from Foodshare.
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