Food Pantry Participants Perceptions of how Transportation and Pantry use Influences Food Purchases. Carol Seaborn, Ph.D., R.D., C.D, C.F.C.S.

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1 1 Author: Title: Butkus, Krysta Food Pantry Participants Perceptions of how Transportation and Pantry use Influences Food Purchases. The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial completion of the requirements for the Graduate Degree/ Major: MS Food and Nutritional Science Research Adviser: Carol Seaborn, Ph.D., R.D., C.D, C.F.C.S. Submission Term/Year: Spring, 2012 Number of Pages: 103 th edition Style Manual Used: American Psychological Association, 6 I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office. My research adviser has approved the content and quality of this paper. STUDENT: Krysta Butkus NAME DATE: ADVISER: Carol Seaborn NAME DATE: This section for MS Plan A Thesis or EdS Thesis/Field Project papers only Committee members (other than your adviser who is listed in the section above) 1. CMTE MEMBER S NAME: Kat Lui DATE: 2. CMTE MEMBER S NAME: Kerry Peterson DATE: This section to be completed by the Graduate School This final research report has been approved by the Graduate School. Director, Office of Graduate Studies: DATE:

2 2 Butkus, Krysta. Food Pantry Participants Perceptions of how Transportation and Pantry use Influences Food Purchases. Abstract Food pantries alleviate hunger by providing eligible individuals with food, but foodimpoverished individuals are at increased risk of not having reliable transportation. The objectives of this study were to determine how food pantry use influences grocery purchases, if reliable and accessible transportation and associated costs influence grocery purchases, and to determine the diet quality of pantry participants. Sixty food pantry clients from Dunn County, Wisconsin were recruited to participate in the study. Eligible participants met the criteria of having martial status as single, or married with children under the age of 18 living in the home, or senior citizens over the age of 60. Participants had incomes less than 185% poverty level. The data collection methods included a survey and focus groups. Results indicated that respondents were not consuming the recommended number of servings per day for fruits, grains, and vegetables. Thematic analysis of focus groups indicated many transportation and social barriers to accessing food, such as time constraints with caring for children, poor weather conditions, and high food costs. Coping methods to manage transportation issues and obtain affordable food or making foods more affordable, included walking to stores, traveling with others, or strategizing shopping trips by buying food in bulk or lower quality food. Conclusions drawn from this study indicated that transportation constraints and nutrition knowledge barriers were limitations for food pantry participants to meet their dietary needs.

3 3 Acknowledgments I would like to acknowledge the guidance, support, and motivation I have received from my graduate education. The encouragement, and advice I have received from my research advisors, Carol Seaborn, Kat Lui and Kerry Peterson, have taken my educational experience and personal growth to a new dimension. I also would like to thank Lana Anderson, and the staff and volunteers of Stepping Stones Food Pantry for the opportunity to complete my thesis at your facility. The support and guidance I received while completing my thesis project made this research possible. Finally, I would like to thank the University of Wisconsin-Stout Student Research Grant Fund for providing funds to make this research possible.

4 4 Table of Contents... Page Abstract...2 List of Tables...7 Chapter I: Introduction...8 Statement of the Problem...12 Purpose of the Study...13 Research Questions...13 Assumptions of the Study...13 Definition of Terms...14 Limitations of the Research...16 Chapter II: Literature Review...17 Demographics of Food Pantry Participants...17 Trends in Food Pantry Participation...19 Challenges for Food Pantries...20 Economic Hardships...21 Food Preferences Among Food Pantry Participants...25 Perceptions of Food Access and Security among Food Pantry Clients...27 Profile of the Foods Provided by Food Pantries...30 Stepping Stones Food Pantry...33 Summary...34 Chapter III: Methodology...35 Subject Selection and Description...35

5 5 Instrumentation...38 Data Collection Procedures...39 Data Analysis...40 Limitations...41 Summary...42 Chapter IV: Results...43 Respondents Demographics from Survey...44 Food Pantry Influences on Pantry Participants Grocery Purchases...45 Estimation of Pantry Participants Dietary Intakes...48 Transportation Access and Grocery Store Purchases...54 Figure 1: Frequency of choosing not to go grocery shopping because of costs as reported by participants...55 Transportation Distance to Grocery Stores...58 Focus Group Results...58 Barriers to Accessing and Preparing Fresh Produce...59 Transportation Barriers to Acquiring Affordable Food...63 Coping Methods for Transportation Barriers...66 Coping Methods for Accessing Affordable Food...68 Summary...71 Chapter V: Discussion...72 Limitations...72 Conclusions: Transportation Access and Food Attainment...72 Conclusions: Food Purchasing Behaviors...76

6 6 Conclusions: Vehicle Access and Food Purchases...79 Conclusions: Transportation Costs and Food Attainment...81 Recommendations...83 Recommendations for Future Research...83 References...85 Appendix A: Approval by the UW-Stout Institutional Review Board (IRB) for the Protection of Human Subjects...94 Appendix B: Consent forms for the Focus Group and the Consent Forms for the Additional Participants Surveyed...95 Appendix C: Survey Questions...99 Appendix D: Focus Group Questions Appendix E: Agreement or Disagreement to Nine Survey Items Related to Transportation, Transportation Costs, Reliable Vehicle Access, Travel Distances, and Difficulties with Transportation.. 103

7 7 List of Tables Table 1: Education Level of Survey Respondents Table 2: Food Purchases Made at Grocery Stores that Participants Stated were Influenced by Foods Distributed by the Food Pantry Table 3: Frequency of Participant Responses to Survey Questions Regarding Foods Purchased as Related to Purchase Site...47 Table 4: Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by those 60 Years and Older...49 Table 5: Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day for those Younger than 60 Years...50 Table 6: Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by Married Parents...52 Table 7: Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by Single Parents...53 Table 8: Frequency of Participant Responses of Purchase Site for Food when there was Not or was Access to a Vehicle...57 Table 9: Comparison of Miles Traveled to Grocery Stores by Marital Status...58

8 8 Chapter I: Introduction Food insecurity refers to the inability to afford enough food for an active, healthy life (Anderson, 1990). Most adults living in food insecure households report the following: inability to afford balanced meals, inadequacy or running out of food, cutting the size of meals, or skipping meals. At the most severe level, many food insecure adults report hunger due to not having enough money for food or not eating for an entire day (Nord, Andrews, & Carlson, 2008). Numerous studies have shown associations between food insecurity and adverse health outcomes among children, such as: iron-deficiency anemia, acute infection, chronic illness, and developmental problems. In adults, the risk of chronic diseases such as heart disease, hypertension, and diabetes may be more prevalent (Seligman, Laraia, & Kushel, 2010). These adverse health effects appear to be related to food insecurity and the inability to achieve adequate intake, which is the sufficient consumption of food, vitamins and minerals to maintain health (Otten, Pitzi, & Meyers, 2006). The 2010 Dietary Guidelines for Americans provide information on how to make healthy decisions about food eaten, and focus on how foods like fruits, vegetables, whole grains, and low-fat dairy products, as well as the consumption of less sodium, saturated and trans fat, and sugar can help prevent diet-related diseases like diabetes and heart disease (USDA, 2012d). Although information to make healthier food choices is available, there are many barriers that prevent individuals from consuming a healthier diet, which include: level of education, occupation, ethnicity, income, and food insecurity (Cohen, Stoddard, Sarouhkhanians, & Sorensen, 1998).

9 9 Common responses to food insecurity often entail decreased food budget, reduced food intake, and alterations in types of food served (Kendall, Olson, & Frongilo, 1996). With food insecurity, dietary variety decreases and consumption of energy-dense foods increases. These energy-dense foods that commonly comprise of refined grains, added sugars, and added saturated/trans fats, tend to be of poor nutritional quality and are less expensive than fruits, vegetables, dairy, lean meats, and whole grains (Monsivais & Drewnowski, 2007). Thus, U.S. adults living with food insecurity consume fewer servings of fruits, vegetables, dairy, and lower levels of micronutrients including: B vitamins, magnesium, iron, zinc, and calcium (Dixon, Winkleby, & Radimer, 2001; Lee & Frongillo, 2001). These dietary patterns link the food insecure individuals with development of chronic disease (Vozoris & Tarasuk, 2003). Food insecurity and the known link to chronic disease is an ongoing concern in the United States. With high unemployment rates and a sluggish economy, food insecurity continues to be a concern for many families. In 2009, it was estimated that 43.6 million people were living in poverty in the United States (Nord, Coleman-Jensen, Andrews, & Carlson, 2010). In addition to those living in poverty, it was estimated that 50.2 million people lived in food insecure households, with 33 million of those people being adults and 17.2 million being children (Nord et al., 2010). Furthermore, families headed by a single mother with children comprised 36.6% of the total households living with food insecurity (Nord et al., 2010). Poverty is defined as a family income less than the set income threshold determined by the U.S. Census Bureau based on family size and composition (U.S. Census Bureau, 2010a). Poverty in the United States and Wisconsin is on the rise. The

10 10 U.S. Census Bureau summarized that in % of all children aged 5-17 were part of families living in poverty in the United States (U.S. Census Bureau, 2010a). In comparison, the U.S. Census Bureau also found in 2009 that a slightly higher number, 17.7% of all children aged 18 or younger in Dunn County, Wisconsin, were living in poverty (U.S. Census Bureau, 2010c). Other data of the U.S. Census Bureau indicated that 15.3% of Dunn County, Wisconsin residents were living in poverty in 2009, which was higher than the state of Wisconsin s percentage of 11.6% and similar to the 15.1% poverty rate of the entire United States (U.S. Census Bureau, 2010b). Thus, the percentage of residents living in poverty in Dunn County is higher than the percentage in the state of Wisconsin, and notably more children are living in poverty in Dunn County than the national average (U.S. Census Bureau, 2010b). Poverty directly affects food security among low-income populations. According to the Household Food Security Study, 11.4% of Wisconsin residents were living in food insecure households between 2007 and 2009, and 4.4% of Wisconsin residents were living in very-low food security homes indicating hunger (Nord et al., 2010). To illustrate the extent of the increasing food insecurity problem, the percentage of Wisconsin residents who were living in food insecure homes increased by 2.5%, and those living in very-low food security households increased 1.7% since the national survey was completed in 2006 (Nord et al., 2010). Also, families with children headed by a female of black or Hispanic ethnicity increased the odds for living in a household with food insecurity (Nord et al., 2010). Food insecurity for low-income families and seniors in Wisconsin is on the rise, and efforts are being made to address this issue at the community level through food pantries.

11 11 Food pantries such as Stepping Stones Food Pantry, located in Dunn County, Wisconsin, help low-income families to meet food needs every month. Stepping Stones Food Pantry is the largest food pantry in Dunn County and serves more than 2000 households every month, with the majority of participants being families with children and the elderly (L. Anderson, personal communication, July 13, 2011). Food pantry participants of Stepping Stones Food Pantry are allowed to use the pantry services on an as needed basis and are provided with enough food for everyone in the household for approximately 4-5 days (L. Anderson, personal communication, July 13, 2011). Stepping Stones receives food resources from Feed My People, a food bank located in Eau Claire, Wisconsin as well as from members of the community. The food that is donated to Feed My People comes from a variety of sources including commercial businesses, government agencies, and members of the community (Feed My People, 2010a and 2010b). Although the facilities of Stepping Stones Food Pantry provide a space for frozen and fresh produce and provide healthy, nutrient-rich foods, research on how well Stepping Stones Food Pantry and Dunn County provide for those in need is minimal. Attitudes among food pantry participants about how transportation and pantry use influence food purchasing have not been well-documented. Research has described that transportation to grocery stores is perceived as being limited in rural communities (Garasky, Morton & Greder, 2004). Research has also described that rural food pantry participants perceive a lack of access to grocery stores with affordable food (Garasky et al., 2004). Despite the notion that food pantry participants report having strong food preferences for fresh fruit and vegetables (Campbell, Hudson, Webb & Crawford, 2011), food pantries were described as having limited amounts of fresh produce and meat

12 12 products (Campbell et al., 2011; Mabli, Cohen, Potter, & Zhao, 2010). Reliable transportation is described as having access to a reliable vehicle all of the time. Having access to a reliable vehicle allows a person to travel places and obtain food. The distance needed to travel to a food shopping center can impact where people shop for food and how frequently they are able to go food shopping. Previous research has emphasized that low-income urban dwellers that traveled more, consumed more fast food (Jilcot, Moore, Wall-Bassett, Liu, & Saelens, 2011). However in this same study, participants that who traveled longer distances shopped more frequently at supermarkets (Jilcot, et al., 2011). Other research has found that low-income residents without employment were more likely to not have consistent reliable transportation (Garasky, Fletcher, & Jenson, 2006). Statement of the Problem How transportation costs and reliable transportation to grocery stores affect the food choices of those who use food pantries is not well documented in research. There appears to be limited studies on how reliable transportation, transportation costs, and other food access barriers affect food attainment and food purchases of pantry participants in rural areas. Rural areas are known to have lower numbers of grocery stores than urban areas, which may also decrease the choices residents of rural areas have for grocery shopping. Transportation to area grocery stores becomes more difficult for rural residents since these individuals need to travel further to obtain needed groceries. More research is needed locally to determine how the food the pantry users receive at Stepping Stones influences purchases at grocery stores.

13 13 Purposes of the Study The major focus of this study was to document how transportation and food pantry use influences food purchases made by food pantry clients. The purpose of this research was to determine 1) how transportation and food pantry use influence grocery purchases, 2) if transportation costs affect food purchases, and 3) if food pantry participants enrolled in the services at Stepping Stones Food Pantry in Dunn County, Wisconsin, were consuming adequate portions of food from each of the food groups as determined by the MyPlate guidelines (USDA, 2012a). More specifically, the following questions were addressed in the research. Research Questions 1. Are there relationships between the miles traveled to grocery stores, access to reliable transportation, and the consumption of specific food groups among food pantry clients? 2. What food purchasing behaviors do food pantry clients use when grocery shopping for food, and how does this relate to what pantry clients receive from the food pantry? 3. How does having access to a reliable vehicle influence food pantry participants specific food group purchases at grocery stores? 4. Do travel costs to grocery stores affect the frequency of grocery shopping by food pantry clients? Assumptions of the Study This study assumed the Stepping Stones Food pantry clients represented all food pantry participants in Dunn County, Wisconsin. It was also assumed that the participants

14 14 of this study were truthful and complete with responses to the survey questions and in the focus group sessions. Definitions of Terms This section provides the definitions of terms that are used throughout this research paper to assist the reader. Dietary Guidelines for Americans. Recommendations for Americans older than two years of age that emphasize balancing calories and physical activity, consuming more high-nutrient dense foods, and consuming less high calorie dense foods. These guidelines are issued and updated every five years by the USDA and the Department of Health and Human Services to help Americans maintain a healthy weight, reduce risk of chronic disease, and promote overall health (USDA, 2012a). Food bank. An organization that obtains donated and bulk-purchased food from food manufacturers, growers, processors, grocery retailers, and distributors. The food is then distributed to food pantries, soup kitchens, and shelters or other organizations that directly serve families and individuals facing hunger (Second Harvest Foodbank, n. d.). Food insecurity. Includes low food security (reduced quality or variety, but minimal change in diet intake), and very low food security (disrupted eating patterns and reduced intake) (Nord & Coleman-Jenson, 2011). Food pantry. A non-profit organization that distributes food products donated by farmers, food processing companies, charitable organizations, or non-profit agencies such as food banks. Food security. Includes high food security (no reports of indications of food access problems or limitations), and marginal food security (one or two reported

15 15 indications of food anxiety, or food shortage, but little or no dietary or intake changes)(nord & Coleman-Jenson, 2011). Low food security. Represents reduced quality, variety, or desirability of diet. There is little or no indication of reduced food intake (Nord & Coleman-Jenson, 2011). MyPlate. Educational resource released by the USDA in June 2011 to replace the MyPyramid Plan. The purpose of MyPlate is to help consumers build a healthy plate by providing simplified guidelines. The new dietary guidelines introduced by the ChooseMyPlate campaign include: make half your plate fruits and vegetables, make at least half your grains whole grains, and switch to fat-free or low-fat (1%) milk (USDA, 2012b). National School Lunch Program. A federally assisted meal program operating in public and nonprofit private schools and residential child care institutions. It provides nutritionally balanced, low-cost or free lunches to children each school day (USDA, 2012e). Poverty. Following the Office of Management and Budget s (OMB) Statistical Policy Directive 14, the Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty. If a family s total income is less than the family s threshold, then the family and every individual in it is considered in poverty. The official poverty definition uses money income before taxes and does not include capital gains or noncash benefits such as public housing, Medicaid, and food stamps (U.S. Census Bureau, 2010b). Supplemental Nutrition Assistance Program (SNAP). A government-funded food assistance program designed for low-income households that are funded through the

16 16 USDA, which was at one time called food stamps. Funds are distributed within each state to provide benefits for qualifying households to assist in food purchase. The amount of benefits provided to each household under SNAP depends on household size, income and expenses (USDA, 2012c). Thematic coding. A method of organizing qualitative data through the use of classification codes to group major themes, ideas, and interpretations during analysis (Harris, Gleason, Boushey, Beto, & Bruemmer, 2009). Very low food security. Represents reports of multiple indications of disrupted eating patterns and reduced food intake, which is associated with hunger (Nord & Coleman-Jenson, 2011). Women, Infants, and Children (WIC). Serves to safeguard the health of lowincome women, infants, & children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care (USDA, 2010a). Limitations of the Research Due to the size and population used for this study, there are a few limitations. This study only investigated the accessibility, affordability, food purchasing behaviors, and availability of food groups to food pantry participants in Dunn County, Wisconsin. Therefore, the results of this study may not be applicable to other areas of the country or even within the state of Wisconsin.

17 17 Chapter II: Literature Review This chapter provides a literature review of food pantries and food pantry participants in the United States. The demographics of food pantry participants will be discussed, followed by trends in food pantry participation and the challenges faced by food pantries. The economic hardships faced by food pantry participants and coping strategies utilized will be discussed. There will be a discussion of food preferences among food pantry participants. Perceptions of food access as affected by transportation, foods offered at grocery stores, and nutritional quality of food obtained will be reviewed. Finally, a discussion of what foods are typically offered at food pantries and specifically details of the Stepping Stone Food Pantry participants will be provided. Demographics of Food Pantry Participants Food pantry participants represent a portion of the low-income households who are using at least one of the resources available in order to meet monthly food needs. According to the Feeding America Study completed by the USDA, 81% of households that were interviewed used food pantries over soup kitchens or shelters (Mabli et al., 2010). The demographics of food pantry clients were well described, as households with at least one child under the age of 18 living in the home compromised 44% of the food pantry population, while senior citizens represented 20.6% of households (Mabli et al., 2010). Notably, 67% of all food pantry clients were women. The age of pantry participants ranged from 18 to over 65, but the majority of pantry participants that represented 72% of the entire client population were between the ages of 30 and 64 (Mabli et al., 2010). According to the Household Food Security Study an estimated 5.6 million people in the United States used food pantries at some point over a 12-month

18 18 period in 2009 (Nord et al., 2010). The use of food pantries can vary based on household size and income level. Households with children parented by a single mother (13.7%) were more likely to use food pantries than those households without children (3.7%), households with more than one adult (2.9%) or households with elderly members (3.1%) (Nord et al., 2010)). Use of food pantries was higher among Black (8.6%) and Hispanic households (7.6%), than non- Hispanic Whites (3.7). This is consistent with the higher rates of poverty and food insecurity of these minority groups. In spite of the lower use rate, non-hispanic Whites comprised a majority (55%) of food-pantry users because of the larger representation of this ethnic group in the general population (Nord et al., 2010). In 2009, the use of food pantries by households with food insecurity was 15 times more likely than households with food security (Nord et al., 2010). Although lowincome families with food insecurity were more likely to use food pantries, the negative connotation associated with the use of food pantries may prevent some needy families from using its resources (Smith & Morton, 2009). For example, taking free food from a food pantry for individuals may be difficult, because of inability to accept the fact these resources were needed to meet monthly food needs (Smith & Morton, 2009). According to the Household Food Security Study (Nord et al., 2010), approximately 66.9% of households with food pantry users participate in at least one federal food and nutrition assistance program. The majority of food pantry participants were receiving SNAP benefits (48.9%), while 22.6% of households with food pantries participants were enrolled in the National School Lunch Program, and 20.7% of households with food pantry participants were WIC clients (Nord et al., 2010).

19 19 Trends in Food Pantry Participation Recently, the percentage of people using food pantries has increased dramatically. In 2010, the Feeding America Organization provided food to 37 million Americans, including 14 million children, which was an increase of 46% over 2006 when the organization was feeding 25 million Americans, including 9 million children per year (Hunger in America, 2010). In 2010, Feeding America was feeding 1 million more Americans each week than the food bank did in 2006 (Hunger in America, 2010). This indicated that food pantry participants seemed to be relying more on food pantries in order to meet basic food needs every month. In addition, more people have started to use pantries for the first time since In 2005, the average newcomer rate was 14.0% per month, while in 2009 this rate increased to 20.8% new food pantry participants per month (Mabli et al., 2010). Along with the percentage of new food pantry participants increasing per month, the percentage of food pantries that were serving more clients from 2005 to 2009 increased 74.3% (Mabli et al., 2010). The various populations food pantries serve over the year can vary by season. In the summer months, more families with children have been identified as using food pantries compared to other times during the year (Nord et al., 2010). In contrast, the number of migrant workers who used food pantries during the winter months increased as well. Food pantries have also stated that during the holiday months, additional clients will begin to use food pantries (Mabli et al., 2010). In addition, food pantry use varies across the nation. Of all regions in the United States, the Midwest was shown to have the highest census of food pantry participants compared to the Southern, Northwestern, and Western regions (Nord et al., 2010). This participation in food pantries in the Midwest is in sharp

20 20 contrast to the states who have the lowest and very lowest food security which are: Mississippi, Texas, Arkansas, Alabama, Georgia, Ohio, Florida, California, and North Carolina (Hunger in America, 2010). Along with the trend of increased food pantry clients, the percentages of food pantry participants that are living in low food security or very low food security households increased from According to the Feeding America Study completed for the USDA in 2010 (Mabli et al., 2010), the number of food pantry participants who were living with low food security increased from 39.1% in 2005 to 41% in The number of food pantry clients who were living with very low food security had also increased from 31.1% in 2005 to 35% in Food pantry participants who were receiving Supplemental Nutrition Assistance Program (SNAP) benefits increased from 36.3% in 2005 to 38.5% in However, the percentage of food pantry participants that were not receiving SNAP benefits, but were eligible, has also increased from 35.1% to 39.3%. These data indicate that the proportion of participating food pantry users are increasing, and the proportion of food pantry participants who are not using federal food and nutrition assistance programs is staying the same. This implies that eligible food pantry participants are not utilizing all of the resources available to them to obtain nutritious food. Challenges for Food Pantries Food pantries face many challenges because of the increasing number of clients. Insufficient funding and food supply shortages are major challenges for food pantries (Mabli et al., 2010). Food pantries have tried to prevent food shortages of staple foods, such as grain products and meats, by limiting the number of staple foods that can be

21 21 taken by each family. At the Stepping Stones Food Pantry, rules to prevent shortages of staple foods also apply. With hundreds of families visiting the Stepping Stones Food Pantry every week, keeping essential food items in stock is challenging. Allowing food pantry participants to take needed essential food products is important so families can be fed; however, this can become problematic if one family takes a large portion of a food pantry s stock of one item (Akobundu, Cohen, Laus, Schulte, & Soussloff, 2004). This may cause the inability of other families to obtain staple foods. Other reasons why food pantries may have problems providing for the needs of participants appears to be due to shortages in volunteers or not enough paid staff. In the Household Food Security Study compiled by Nord et al. (2010), results indicated that 67.7% of pantry programs, 42% of kitchen programs, and 15.3% of shelter programs had no paid staff. Other confounding results indicated that pantry programs had on average six volunteers per week (Nord et al., 2010). These data indicate that food pantries may not have the adequate staff to adequately man, stock, and maintain food pantries. Therefore, among all food pantries that participated in the Feeding America study, 66.6% of all food pantries were facing at least one problem associated with staffing, refrigeration/freezers, and lack of donations in meeting the food needs of clientele (Mabli et al., 2010). Economic Hardships In rural communities, poverty rates can be as high as 15.1% of the community s total population. According to the U.S. Census Bureau in 2010, between 2006 and 2010 the percentage of people living in Dunn County, Wisconsin who were poverty stricken was 14.2% (U.S. Census Bureau, 2010c). By comparison, the percentage of people living

22 22 in poverty in 2006 to 2010 for the state of Wisconsin was lower at 10.5% (U.S. Census Bureau, 2010c). The percentage of people living below poverty in Dunn County was also much higher than the national average of 12.9% (National Alliance to End Homelessness, 2010). These data indicate that Dunn County has a much higher percentage of its residents living in poverty compared to the state and national averages. Hardships for food pantry participants. The poor economy has drastic consequences for those that live in poverty. According to a report completed by the Economic Research Services (Gibbs, Kusmin, & Cromartie, 2005), food insecurity in rural areas was considered to be more extreme than in urban or suburban areas because of lower educational status, concentration of employment in lower-wage businesses, and higher unemployment rates. Besides these general economic hardships for rural lowincome individuals, those that use food pantries have additional hardships. Biggerstaff, Morris and Nichols-Casebolt (2002) stated that economic hardships for food pantry and soup kitchen participants could be classified into three categories: housing and family situations, loss of public benefits, and distribution of utilities. Those food assistance participants who experienced housing or family situations described being homeless, victims of domestic violence, or having to let other people move in to help pay expenses. Others suffered from loss of public benefits, the loss of food stamps, Medicaid, or health insurance. Those with disruption of utilities because of non-payment of bills experienced cut offs of phone service, electricity, or heat (Biggerstaff et al., 2002). Senior citizens, a specific subgroup that use food pantries, have emphasized that after spending money on bills and medications, limited funds for food are available at the

23 23 end of the month (Keller et al., 2006). Other hardships described for seniors that make paying bills or obtaining food difficult include having less than a high school diploma, being disabled or unemployed, or living alone (Ziliak & Gundersen, 2009). Economic hardships throughout the rural community. Besides economic hardships occurring for pantry participants, hardships have been portrayed throughout the rural communities for this population. Research has depicted that rural communities tend to have fewer grocery stores available for community members compared to urban or suburban areas (Garasky et al., 2004). Because fewer grocery stores are available in rural communities, families in rural areas may need to travel further to access food. And some low-income residents living in rural communities have expressed that the cost of food was higher in the local community compared to areas that were further away (Smith & Morton, 2009; Webber, Sobal, & Dollahite, 2010). But some low-income rural residents emphasized that even though grocery stores were cheaper further away, considering the cost of gasoline to travel there would make the total cost the same (Smith & Morton, 2009). Also, low-income residents in rural counties of Minnesota and Iowa have expressed the desire for more community grocery stores so prices of the foods could be compared even though some of those prices were expected to be more expensive (Smith & Morton, 2009). Although previous research has described grocery stores in rural communities to be more expensive than those further away, future research on lowincome rural residents perceptions on the affordability of their food environment may be warranted.

24 24 Price inflation. In addition to the prices of grocery stores in rural communities being higher than urban communities, the annual food price inflation also affects food costs for all communities. In a report completed by the Economic Research Service, the Consumer Price Index for 2011 increased 4.8% for all food. This inflation was predicted to increase an additional 2.5% to 3.5% in 2012 (USDA, 2012b). With the recent and substantial inflation of food prices, low-income populations are expected to continue to struggle with purchasing foods and finding affordable food in the community. In addition, Garasky Fletchen, and Jenson (2006) emphasized that gasoline prices have increased dramatically in the last few years. These gasoline price increases as a result of inflation have caused challenges for families to obtain the necessary funds to afford gasoline. Coping strategies for economic hardships. Although there are many economic hardships for low-income populations, some low-income rural residents have found ways to cope with the high costs of foods and limited numbers of grocery stores in the community. Planting gardens, sharing food with others, buying in bulk, and using coupons or federally-funded government assistance food programs have all been ways low-income rural residents have been able to afford and access food (Smith & Morton, 2009; Hoisington, Shultz & Butkus, 2002). Buying lower-priced fresh produce and lower-quality meat products were also coping strategies (Leibtag & Kaufman, 2003). Other coping strategies low-income households use to stretch food during the month were making or buying food in bulk, using leftovers, or freezing food for later use (Hoisington et al., 2002). Senior citizens have described eating at family or friends houses to save money on food costs (Keller et al., 2006). Food pantry participants bought canned or

25 25 frozen fruits and vegetables instead of fresh (Hoisington et al., 2002), or used fresh produce in the beginning of the month, and canned or frozen at the end of the month to help save costs (Webber, Sobal & Sollahite, 2010). However, other research suggests that when purchasing power in the home decreases due to a loss of income, low-income populations have been shown to use less nutrient-dense foods, buy less food, skip meals, or reduce overall intake (Ruel, Garrett, Hawkes, & Cohen, 2010; Wood, Shultz, Butkus, & Ballejos, 2009). Food Preferences among Food Pantry Participants Healthy balanced meals are an important part of having a healthy life, and this concept is not viewed differently among food pantry users. According to food pantry participants, having meats, poultry, fish, fruits, and vegetables available at food pantries was viewed as very important. Specifically, fresh fruits vegetables such as tomatoes and apples were also viewed as important items to be offered at food pantries according to the pantry participants (Campbell et al., 2011). Notably, food pantry participants preferred fresh fruits and vegetables to canned or frozen produce. On the other hand, food pantry users viewed candy, soda and snack items as not very important items to receive at food pantries (Campbell et al., 2011). In addition, low-income rural residents have emphasized that quality, smell, texture, and appearance were also important when purchasing food at grocery stores (Smith & Morton, 2009; Keller et al., 2006). Nevertheless, rural communities with few grocery stores often have limited quantities and varieties of foods to purchase (Webber et al., 2010). Therefore, having access to healthy nutritious food at food pantries was described no differently than the grocery store limitations in rural areas by food pantry participants (Campbell et al., 2011; Smith & Morton, 2009).

26 26 The nutritional quality of foods that food pantry users do choose can be improved. Food pantry participants in Massachusetts chose foods that represented the least amounts of servings from the fruit and dairy groups (Akobundu, Cohen, Laus, Schulte, & Soussloff, 2004). Results of the study indicated that the estimated number of days that the fruit and dairy products food pantry participants obtained would last only three days. Other findings from the study indicated that food pantry participants obtained fats, oils, and sweet products in the largest quantities, while grains were chosen in the next largest quantity, followed by vegetables and meats (Akobundu et al., 2004). Food pantry participants could obtain five days worth of vegetables and meat servings, and seven days worth of grains by consuming the food taken from the food pantry to meet daily-recommended servings for these food groups (Akobundu et al., 2004). This indicates that food pantry participants are able to access healthy food at food pantries, but not in the quantities needed to meet the USDA recommended daily servings for all food groups to last for seven days. Food pantry participants are not limited to the number of pantries used every month to access the food needed by the family. The number of pantries that a household will use every month to access enough food can vary from using only one or up to five food pantries in a given month (Campbell et al., 2011). According to the Feeding America Study, 60.4% of adult food pantry participants expressed satisfaction with the amount of food received when going to the food pantry. In addition, the percentage of adult food pantry participants who were very satisfied with the variety of food received when going to a food pantry was slightly lower at 57.5% (Mabli et al., 2010). Thse data indicate that there is room for improvement with how food pantries can deliver food to

27 27 the clients served. Perceptions of Food Access and Security Among Food Pantry Clients Transportation access. Access to affordable food for food pantry participants is not always feasible due to lack of reliable transportation. According to a study conducted by Garasky et al. (2004), lack of access to affordable transportation has been depicted to significantly increase the likelihood of being food insecure when living in rural communities. In addition, limited access to private transportation significantly increased the odds of not having employment (Garasky et al., 2006). Unemployment reduces income, and therefore, funds to afford food and groceries. Other research suggests that residents living in deprived rural communities had longer travel times to stores with fresh produce than those residing in less deprived rural communities (Smith et al., 2010). Although affordable transportation was limited to local grocery stores in rural and suburban areas of Iowa, food pantry participants described that the shopping centers used were safe (Garasky et al., 2004). Senior citizens have difficulties accessing transportation for various reasons as well. Senior citizens that used grocery store delivery services have complained that the foods delivered were expired, of poor quality and not senior-friendly (Keller et al., 2006). In addition, seniors have emphasized that public transportation such as buses or taxis limit the ability to purchase all the foods needed because of only being able to purchase what could be carried (Keller et al., 2006). Research has characterized that many senior citizens do not have access to a vehicle, or do not have a valid drivers license. To access food, seniors have shared that family and friends assist in grocery shopping or provide rides to the stores to obtain groceries (Keller et al., 2006). However, seniors have also

28 28 positively affirmed enjoyment by being able to purchase food from convenience stores nearby, but also expressed concerns about prices at those locations as being higher (Keller et al., 2006). These limitations for food purchasing may impose on the nutritional quality of the foods that seniors purchase. Perceptions of food offered at grocery stores. Having the ability to purchase affordable food at local grocery stores in rural areas is important to food pantry participants, since use of food pantries is not the only source of acquiring food for this population. Rural food pantry participants use food stamps as another source of accessing affordable food through grocery stores (Garasky et al., 2004, Wood et al., 2009). Senior citizens have expressed concerns about shopping at grocery stores because labels were hard to read or becoming tired of shopping in stores due to fatigue (Keller et al., 2006). Seniors have difficulties viewing the nutritional quality of the foods purchased and the need to make grocery shopping trips shorter may cause the inability to purchase all foods needed. This could result in a nutritionally inadequate diet. Low-income individuals have varying opinions on the food variety offered in the local community. The need for having a variety of food at grocery stores is important for low-income individuals who express that varieties of food are limited to those that the store perceives that the community wants, when in fact, that may not always be the case (Smith & Morton, 2009). Low-income rural residents also believed that because there were fewer food shopping centers in local communities, the grocers that were available were over inflating food prices (Smith & Morton, 2009; Hendrickson, Smith & Eikenberry, 2006). Other research has depicted that low-income individuals in urban areas confirmed

29 29 shopping outside of the community, because nearby grocers had limited food choices (Hendrickson et al., 2006). However, low-income rural residents still shop within the community to support neighborhood businesses (Hendrickson et al., 2006), and do not shop outside of their community because the cost it takes to travel outside of the area is too high (Garasky et al., 2006). Yet, in some cases, rural low-income individuals buy food outside of the community, because prices were lower (Keller et al., 2006). Food security in the home. In order to make meals affordable for the whole family, food pantry users will stretch food to make meals large enough for the entire family. A study conducted in the state of Washington found that food pantry participants would add more filler ingredients such as noodles and potatoes to dishes to stretch the meat and vegetables in their meals (Wood et al., 2009) These filler foods vary in nutritional content and can severely limit the nutritional quality of the foods food pantry participants consume (Wood et al., 2009). Food pantry participants were also found to lock the kitchen cabinets or eat smaller meals. However, limiting the amount of food the family could have by locking cabinets or eating smaller meals was found to be associated with poor child nutrition and food insecurity (Wood et al., 2009). Nutritional quality of food accessed. Food pantry participants have also expressed concerns about the nutritional quality of the family s diets. Low-income families have expressed complaints about how it is difficult to consider nutrition when the family is hungry. Families who were using food stamps have also perceived that it was difficult to buy nutritious foods with food stamps, since the cost of those nutritious foods was so high compared to less nutritious food (Hoisington et al., 2002). Seniors have expressed that eating nutritious food was important to them, but due to limited

30 30 funds, transportation constraints, and the needed convenience when eating alone, less nutritious, less tasty and more convenience foods were purchased (Keller et al., 2006). Buying nutritious foods becomes more of a challenge for the low-income family when a household member loses a job, or if the household runs out of food stamps early in the month (Hoisington et al., 2002). The specific nutrient intake of food pantry participants is somewhat described by research. The percentage of food pantry participants in Quebec that met the dailyrecommended servings of dairy products was 21% (Starkey, Gray-Donald, & Kuhnlein, 1999). This percentage, although low, was similar to the general population who were able to meet the daily serving requirements for dairy. Both of these percentages are considered inadequate, and efforts should be taken to improve dairy consumption for both the general population and food pantry participants. Although dairy consumption was lower for both the general population and food pantry participants, calcium intake was much lower for food pantry participants than the rest of the population (Starkey et al., 1999). In addition, research has indicated that food pantry participants have inadequate intakes of the B complex vitamins, vitamin C, vitamin A, magnesium, iron, calcium, and zinc; whereas, the pantry participants have adequate intakes of protein, fiber, iron and folate (Akobundu et al., 2004; Dixon, Winkleby, & Radimer, 2001; Lee & Frongillo, 2001; Starkey et al. 1999; Tarasuk & Beaton, 1999). Profile of the Foods Provided by Food Pantries In West-central Wisconsin, which includes Dunn County, food pantries receive food from the food bank, Feed My People. Feed My People provides a cost-effective means to provide food and technological support to all the surrounding food pantries

31 31 served. According to Feed My People (2010a), more than 85 agencies in 14 counties are provided with food distributed from this food bank. The food pantries, soup kitchens, and shelters supported by the Feed My People food bank serve over four million meals every year by the food distributed. Food pantries can use facility-owned vehicles to transport food goods from the food bank to the food pantries, soup kitchens, and shelters. In other cases, food banks will provide transportation of food goods to the foodshelf (Rochester, Nanney, & Story, 2011). In all cases, regardless of transportation costs, food pantry participants will not have to pay for the foods received. Although food pantries have many benefits, there are some limitations. Food pantry limitations include the amounts and types of food that can be brought in and served to their pantry participants. For example, food pantries may not have the adequate refrigerator or freezer space needed to store sufficient amounts of fresh produce, vegetables, or fruits to meet the recommended amount of fresh fruits and vegetables as stated by the Dietary Guidelines of America 2010 (USDA, 2012d). Due to limitations in storage space, food pantries may perceive the ability to store and access fresh fruits and vegetables as being insufficient to their needs (Rochester, Nanney, & Story, 2011). Food pantries have various ways of implementing policies throughout the facility. According to one study, a large majority of food pantries have food sourcing policies written describing that nutritious and culturally-appropriate food should be provided by the pantries. However, the majority of these policies are informal (Rochester et al., 2011). Although food pantries may have policies that state healthy and culturally appropriate foods should be distributed to food pantry participants, implementation of these policies requires availability of enough healthy foods to uphold these policies. Unfortunately, the

32 32 inadequate refrigerator and freezer space and the lack of community donations of nutritious foods have prevented food pantries from meeting these policy recommendations (Rochester et al., 2011). Volunteer staff, versus paid staff, was also seen as a limitation to upholding policy recommendations (Rochester et al., 2011). As a comparison, Stepping Stones Food Pantry does not have any formal food distribution policies, and runs primarily on volunteer staff (Stepping Stones, 2011). Along with food pantries perceiving the access to fresh fruits and vegetables as inadequate, food pantries also perceive the ability to access lean meats, low-fat dairy products, and cereals low in sugar as inadequate. Access to canned goods, on the contrary, was perceived as being adequate (Rochester, Nanney, & Story, 2011). Along with not having enough storage space for fresh produce, corporate community donors of food pantries may not always provide food pantries with healthy food options all of the time, which may limit the amount of nutritious food distributed (Rochester, Nanney & Story, 2011). The food sources that food pantries utilize vary from day to day. As community, government agencies, and local businesses provide a large majority of the foods provided to food pantries, the products received by pantries are never constant. These variations of foods can cause concerns for the nutritional quality of foods offered at the pantries. According to one study completed in Massachusetts, food pantries were found to have high nutritional quality of fiber, iron, and folate in the foods that were available to food pantry participants (Akobundu et al., 2004). In addition, cholesterol content and saturated fats of the foods were within recommended daily servings. However, foods provided at the food pantries were often low in calcium, vitamin C, and vitamin A (Akobundu et al.,

33 ; Starkey et al., 1999). These data suggest that food pantries are limited in fresh fruits, vegetables, and dairy products, since foods with the highest nutrient quality of vitamin C, vitamin A, and calcium are found in these products. Stepping Stones Food Pantry In recent years, both the amount of food that the Stepping Stones Food Pantry has distributed and the number of people that have utilized the facility drastically increased. In 2010, the number of people who used the food pantry per month was 688 compared to 640 in 2009 (L. Anderson, personal communication, June 13, 2011). Although the number of people who used the food pantry in 2010 stayed relatively the same as in 2009, the number of pounds of food that the Stepping Stones Food Pantry distributed increased from 492,000 pounds in 2009, to over 600,600 pounds of food in 2010 (L. Anderson, personal communication, June 13, 2011). Stepping Stones Food Pantry receives its food from a number of sources, both locally and nationally. Government commodities provide Stepping Stones Food Pantry with approximately 10% of the total food donations. Feed My People food bank, located in Eau Claire, Wisconsin, provides approximately 50% of the total food donated to Stepping Stones Food Pantry. Finally, community members and local shopping centers provide the Stepping Stones Food Pantry with food donations that equal to approximately 40% of total food donations to the food pantry (L. Anderson, personal communication, June 13, 2011). Food pantry participants at Stepping Stones Food Pantry can obtain an average of pounds of food, two times per month. The food normally distributed by the Stepping Stones Food Pantry is an assortment of fresh, frozen, and canned goods. Of the

34 34 food distributed to the food pantry, 30% of the food is fresh and frozen, and the remaining 70% is canned or pre-packaged. The building project of the Stepping Stones Food Pantry took place between 2009 and 2011, which has allowed pantry staff the ability to store and acquire more food for the pantry participants (L. Anderson, personal communication, June 13, 2011). Summary Food access is an important public policy issue across America and in the rural area of Dunn County, Wisconsin. Food pantry clients such as those served by the Stepping Stones Food Pantry in Dunn County are often the most vulnerable households in a community, lacking financial and social resources to solve problems related to food acquisition. Understanding the circumstances under which these families attempt to meet nutritional needs is vital to addressing the problems of food insecurity. Food purchases at grocery stores can be influenced by available transportation, amount of food stamps provided by the government, food preferences, and family income. This study sought to determine if the food choices food pantry clients have at the food pantry influence food choices made at grocery stores, as information regarding this question is not well studied. In addition, transportation costs to grocery stores are known to influence where low-income populations shop, but how transportation costs and proximity to grocery stores affect what foods pantry participants buy as well as how the foods received at food pantries influence food choices and preferences at grocery stores were also examined.

35 35 Chapter III: Methodology This chapter discusses the methodology of the study. First, a description of the subject selection is provided, followed by the instrumentation. Next, this chapter presents the data collection procedures, data treatment, and analysis procedures. Lastly, the chapter concludes with a description of the limitations of the methodology that relate to the subject selection, instrumentation, and data collection procedures. This study incorporates both qualitative and quantitative research methods to gather the most in-depth and accurate data from participants. Qualitative data were collected by use of questions from the survey given to qualifying participants who participated in the Stepping Stones Food Pantry. The qualitative research data were obtained from three focus group sessions that were composed of qualifying participants from Stepping Stones Food Pantry. Subject Selection and Description After approval by the University Wisconsin-Stout Institutional Review Board (IRB) for the Protection of Human Subjects in Research, subjects for this study were recruited from the Stepping Stones Food Pantry located in Dunn County, Wisconsin. See Appendix A for the IRB approval memo. Eligible participants were either married or single with children under the age of 18 living in the home, or senior citizens over the age of 60. Participants from each of these groups were eligible to join in the focus group sessions and survey. Subject selection was based on the knowledge that single, married, and elderly populations were the most representative populations served by the Stepping Stones Food Pantry, as well as the most common groups who utilize food pantries (Biggerstaff, McGrath-Morris, & Nichols-Casebolt, 2002). To be eligible for benefits

36 36 from Stepping Stones Food Pantry, individuals provide proof of residence in Dunn County. Also, in order to be eligible for benefits from the food pantry, households were required to have an income lower than 185% federal poverty level (Stepping Stones, 2011). For a household of four members or one member, the qualifying income is less than $796 or $388 per week, respectively (Food and Nutrition Service, USDA, 2012). Therefore, residence and income were controlled among the participants in this study. The Stepping Stones Food Pantry was the preferred location to conduct the study because the pantry serves over 2,000 pantry participants every month, making it the largest pantry in the county. Therefore, this is the most representative sample of food pantry participants in the area. In order to maximize participant selection for the focus groups, the researcher was present on the busiest days of the month during October 2011, when potential focus group participants were known to attend the food pantry. After communicating with the pantry coordinator, it was decided that pantry participants at Stepping Stones Food Pantry attended in the largest numbers at the beginning of the month, since it was during this time federal assistance would arrive for the families. Single or married parents were expected to come to the food pantry in largest numbers on the first Tuesday and Wednesday of the month. Adults over the age of 60 were known to attend in the largest numbers on the first Thursday of every month, since this was when they received commodity boxes. Focus group sessions were planned prior to recruiting participants in order to minimize scheduling difficulties for finding available times for all focus group participants to meet. The focus group sessions were scheduled to occur one month after

37 37 recruitment. Similar times to the recruitment efforts were utilized in scheduling the focus groups. The single parent focus group was held on the first Tuesday in November; the married parent focus group was held on the first Wednesday in November; the senior focus group was held on the first Thursday in December. Timing of all three focus groups occurred approximately two hours before the pantry opened to maximize turnout rates. Discussions with the pantry coordinator assisted in scheduling the focus group sessions. An initial screening of all pantry participants occurred when clients came to the intake desk when first arriving at the food pantry. The receptionist at the desk screened the participants to determine eligibility for the research study by asking the participants the following questions: single, married, or older than 60, and if any children under 18 years were present in the household. Every eligible participant was requested to speak to the researcher about participating in the study. Participants who presented themselves to the researcher were given an explanation of the study, and what was required from them in order to participate in the study. Upon initial agreement to participate, participants were asked to leave a name and phone number with the researcher, and were given an invitation to attend a focus group on a specific date and time that the focus group interview and survey would be completed. The day and time ensured that each of the three subject groups were composed of similar participants, either single or married with children under age 18 or adults older than 60. Once 20 participants were obtained for each focus group, the focus group subject selection was complete. Two weeks prior to the focus group sessions, a letter was sent by mail to each participant that initially agreed to participate in the study to increase the turnout rates for the focus group sessions. The food pantry coordinator mailed the letters, since access to

38 38 the participant s addresses was not permitted to the researcher. The phone record for each participant interested in the study was provided if no mailing address was recorded. Follow-up phone calls were made by the researcher a day or two before the focus groups to increase the turnout rates as well. If subjects did not answer, a phone message was left, if available. Those subjects who were not able to have a message left were called a maximum of two times. Due to the limited turnout rates of the focus groups (n = 17), surveys were obtained from additional pantry participants who met the criteria described above (married or single with children under the age of 18 living in the home, or senior citizens over the age of 60). Again, the researcher was present at the busiest days the pantry was open, to obtain the largest numbers of eligible pantry participants to complete the survey. Consent forms were provided to all participants who showed interest in participating in the study to ensure understanding of the purpose of the study. See Appendix B for consent forms for the focus group and the consent forms for the additional participants surveyed. The researcher also briefed each subject on the purpose of the survey and time commitment for the study for further clarification. Forty-three additional surveys were completed during the second survey data collection phase. Instrumentation The development of the survey was constructed through discussions with the Food Pantry Coordinator at Stepping Stones Food Pantry and the researcher s advisor. The questions were formatted quantitatively or qualitatively to provide the researcher with the most accurate information. See Appendix C for the survey questions. The average reading level in the United States is the sixth grade; therefore, surveys were

39 39 written at a sixth-grade reading level to increase understanding and comprehension of the surveys. Surveys were also written in a 12-point font to ensure readability. Some questions required short written answers but participants were informed of the time commitment of 10 minutes to complete the survey in the consent form provided with the survey. The surveys were distributed to all families or food pantry participants who gave consent on the days the researcher was present. The researcher, the researcher s committee members, and the pantry site supervisor collaborated to develop the focus group questions (See Appendix D). Questions were formatted as open-ended questions to facilitate discussion. Focus groups were used as part of the data collection to obtain further detail about the research topics that would be difficult to gather from a survey. All questions were asked at all focus group sessions. Questions were formatted so that the more sensitive questions were asked toward the end of each of the focus group discussions. Before the focus group sessions, the researcher summarized the consent form out loud as an additional measure of clarification of the study s purpose for the participants. Data Collection Procedures Before the study began, subjects were informed that participation was voluntary, and that no negative consequences would occur if subjects chose not to participate. Consent to participate in the study was obtained from a consent form that was approved by the UW-Stout IRB. Consent forms (see Appendix B) were distributed to participants prior to beginning the focus group sessions or prior to the distribution of surveys to additional pantry participants who were not part of the focus groups. Each subject was informed of the purpose of the consent form and given a brief description of the study

40 40 and its purpose at the time the survey was distributed. Subjects completed the survey prior to beginning the focus group sessions. Once all participants were finished with the surveys, the focus group sessions began. All focus groups were tape-recorded so that the researcher could later transcribe the sessions. Participants were informed that the sessions would be recorded prior to beginning the discussion. Clarification of all questions was provided as needed, and probing questions were used to facilitate further discussion and to focus in on responses related to each of the questions asked. At the end of the focus groups, all participants were provided a token of appreciation that was comprised of fresh fruit and vegetables, MyPlate magnets, information on shopping on a budget, and kid-friendly foods (parent groups only). The contents of the gifts bags were provided through the support of the University of Wisconsin-Stout Student Research Grant Fund. Data Analysis Data were analyzed following data collection from the focus groups by identifying trends and themes between food purchasing behaviors, perceptions of the food pantry, and transportation access to grocery centers. The researcher performed data coding on the focus group results and a statistical consultant at UW-Stout performed data analysis on survey data collected. Responses were analyzed using SPSS (Statistical Package for the Social Sciences, Version 18) statistical analysis software. The survey items were analyzed using descriptive statistics including frequencies, means, standard deviations, and percentages. Statistical significance was judged using a significance level of 0.05 using 2-tailed tests, where appropriate. A test statistic was

41 41 considered statistically significant if the calculated significance value was equal to or was less than The focus groups were analyzed by first transcribing the audiotape from each focus group. Responses from all focus group transcripts were then complied together according to questions and common responses. After data for all questions were organized and categorized, responses were analyzed for trends, patterns, and common themes. Similar responses to each question were grouped together and were compared and contrasted among questions in order to identify and strengthen themes and participant viewpoints. Limitations This research was limited to those subjects who chose to participate in the focus group sessions or who chose to complete the survey. This research was also limited to subjects who used Stepping Stones Food Pantry in Dunn County, Wisconsin. Therefore, this study gathered information on food pantry participants that resided within Dunn County, Wisconsin, which may not be representative of food pantries in other areas. Also, focus group sessions had small turnout rates, which could have resulted in some bias as the opinions and viewpoints of a larger number of pantry participants were missing. Some questions asked participants to state how many serving sizes of each of the food groups they consumed on average in the last week; therefore, some participants may have over or underestimated serving sizes due to lack of knowledge of serving sizes or limited memory on the average number of servings consumed during the last week for each food group.

42 42 Summary Food insecurity is an enormous public health issue. Responses to a decreased food budget include decreased intake of fruits, vegetables, dairy, lean meats, and whole grains. The increased consumption of energy-dense food of poorer nutritional quality can decrease levels of micronutrients and lead to development of chronic disease. Food pantries such as Stepping Stones Food Pantry in Dunn County, Wisconsin, help those who are food insecure meet food and basic nutritional needs each month. How access to and cost of transportation affect food purchase is not well researched. The methodology discussed in Chapter 3 documents how transportation issues and food received at food pantries influences food purchases at grocery stores. Chapter 4 outlines the results gathered from both quantitative and qualitative data collection procedures. Chapter 5 discusses the significance of the findings.

43 43 Chapter IV: Results This study aimed to determine how transportation and food pantry use influences food purchases made by food pantry clients enrolled in the services at Stepping Stones Food Pantry in Dunn County, Wisconsin. The purposes of this research were to determine 1) how transportation and food pantry use influence grocery purchases, 2) if transportation costs affect food purchases, and 3) if food pantry participants of Stepping Stones Food Pantry were consuming adequate portions of food from each of the food groups as determined by the MyPlate guidelines (USDA, 2012c). The two phases of research, completion of a survey and focus groups sessions were used to answer the following research questions: 1. Are there relationships between the miles traveled to grocery stores, access to reliable transportation, and the consumption of specific food groups among food pantry clients? 2. What food purchasing behaviors do food pantry clients use when grocery shopping for food, and how does this relate to what pantry clients receive from the food pantry? 3. How does having access to a reliable vehicle influence food pantry participants specific food group purchases at grocery stores? 4. Do travel costs to grocery stores affect the frequency of grocery shopping by food pantry clients? In short, the methods involved the recruitment of Stepping Stones Food Pantry users to participate in the three focus groups and survey. Surveys were distributed to participants before the focus groups began. Following completion of the survey, the focus

44 44 groups were conducted. Focus groups were used to provide additional in-depth information, which the survey alone could not achieve. To elicit more data, additional food pantry participants were recruited to complete the survey after the focus group phase of the research was completed. Focus groups were analyzed using thematic analysis and coding, while surveys were analyzed using descriptive statistics and two-tailed t-tests. This chapter will describe the results of these analyses as they relate to the research questions. The data from the survey are first discussed followed by the focus group results. Respondents Demographics from Survey A total of 60 respondents completed the research survey. This sample included 52 females, and 7 males. One respondent did not report his or her gender. Ages ranged from 18 to 84. The average respondent age was 45.7 years, and the mode age reported was 28. Respondents who reported an age less than 60 years comprised 66% (n = 39) of the total sample. One respondent did not report his or her age. With regards to marital status, 55% (n = 33) were single or divorced, while the remainder of the respondents were married 45% (n = 27). Survey respondents were asked to report how many children under the age of 18 were living in their home. The responses ranged from 0 to 9 children. Of those respondents who were under the age of 60, the average number of children who lived within the household who were under the age of 18 years was 3; for those over the age of 60 years, the average number of children living in the household who were under the age of 18 was 0. When respondents were asked to identify the highest level of education completed, responses ranged from less than a high school diploma (n = 7) to a 4 year

45 45 Bachelor s degree (n = 5). As described in Table 1, respondents who had a high school degree made up 41.7% (n = 25) of the sample, while those with some college education made up 33.3% (n = 20) of the sample. Table 1 Education Level of Survey Respondents Response Frequency Percent Less than high school diploma High school diploma or GED Some college, no degree year degree (Associate s) year degree (Bachelor s) or higher Total Note: Frequency reported as n. Food Pantry Influences on Pantry Participants Grocery Purchases In order to gain insight on how the food pantry influences food purchases of pantry participants at grocery stores, respondents were asked to indicate if pantry use influences food purchases. This survey item was added after the focus group sessions were completed in order to gain further information on the food purchases made by the additional pantry participants surveyed (n = 43). Respondents for this question were not part of the focus group sessions. Respondents were asked to indicate either a YES or NO response, followed by specifying exactly what foods purchases were influenced. The responses of those respondents who selected YES that food purchases are affected by pantry use are depicted in Table 2. Respondents indicated that using the food pantry

46 46 influenced 63.3% (n = 21) of fruit purchases, 54.5% (n = 18) of dairy purchases, 51.5% (n = 17) of meat purchases, 48.5% (n = 16) of vegetable purchases, and 33.3% (n = 11) of grain purchases, while 6.1% (n = 2) of respondents indicated that using the food pantry influenced other purchases. Table 2 Food Purchases Made at Grocery Stores that Participants Stated were Influenced by Foods Distributed by the Food Pantry Food Group Frequency Valid Percent a Fruit Dairy Meat Vegetables Grains Other Note: Frequency values represent the number of times each food group was chosen by participants who indicated pantry use influenced food purchases. Participants were able to select more than one choice (n=33). a Only participants who did not participate in focus groups responded to this survey item. In order to determine how food purchases related to the purchase site, survey respondents were asked to indicate where various foods were obtained (see Table 3). Results indicated that 60% (n = 36) of fresh vegetables were obtained at grocery stores, while 60% (n = 36) of canned vegetables were obtained at the food pantry. Similarly, 56.7% (n = 34) of fresh fruits purchases were obtained at grocery stores, while 48.3% (n = 29) of canned fruits were obtained at the food pantry. For grain products, 33.3% (n = 20) of refined and enriched grains were obtained from the food pantry. The majority

47 47 of dairy products were obtained at grocery stores, as indicated by the results of 68.3% (n = 41) of dairy product purchases coming from grocery stores. Table 3 Frequency of Participant Responses to Survey Questions Regarding Foods Purchased as Related to Purchase Site Purchase Site Produce Grocery Store Food Pantry Convenient Store Home Garden Family Friend Missing Fresh Vegetables 36 (60) a 21 (35.0) 0 1 (1.7) 0 2 (3.3) Canned Vegetables 19 (31.7) 36 (60.0) (8.3) Frozen Vegetables 34 (56.7) 15 (25.0) 0 2 (3.3) 1 (1.7) 8 (13.3) Fresh Fruits 34 (56.7) 23 (38.3) 0 1 (1.7) 1 (1.7) 1 (1.7) Canned Fruits 20 (33.3) 29 (48.3) 1 (1.7) (16.7) Frozen Fruit 34 (56.7) 8 (13.3) 1 (1.7) 3 (5.0) 1 (1.7) 13 (21.7) Refined Grains 27 (45.0) 20 (33.3) 6 (10.0) 0 1 (1.7) 6 (10.0) Enriched Grains 28 (46.7) 20 (33.3) 3 (5.0) 0 1 (1.7) 8 (13.3) Dairy Products 41 (68.3) 7 (11.7) 8 (13.3) 0 1 (1.7) 3 (5.0) a Frequency reported as n, parenthesis indicate percent (%)

48 48 Estimation of Pantry Participants Dietary Intakes It was of interest to determine the estimated number of servings consumed from the listed food groups of those respondents who were over and under the age of 60 years, and those who were married or single. A determination of the dietary intakes of these specific groups was sought, since these individuals comprise the greatest numbers that use the Stepping Stone s Food Pantry. Table 4 describes the dietary intakes of those 60 years and older. Results indicated that 52.4% (n = 11) of respondents consumed green vegetables, 52.4% (n = 11) of respondents consumed canned vegetables, and 38.1% (n = 8) of respondents consumed starchy vegetables on average once per day. Seven (33.3%) respondents indicated that frozen vegetables were consumed twice per day. It was estimated that fresh fruits were consumed once per day by 28.6% (n = 6) by subjects who were over 60 years, while canned fruits were consumed on average once per day by 47.6% (n = 10) of the subjects. Frozen fruits were never consumed by 33.3% (n = 7) of the sample. Similarly, 33.3% (n = 7) of the sample consumed refined grains once per day. Five (23.8%) respondents consumed enriched grains four or more times per day. Finally, dairy products were consumed twice a day by 28.6% (n = 6) of respondents 60 years and older.

49 49 Table 4 Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by those 60 Years and Older Produce Never Once Twice Three Times Four or More Missing Green Vegetables 0 11 (52.4) a 7 (33.3) 2 (9.5) 0 1 (4.8) Canned Vegetables 1 (4.8) 11 (52.4) 3 (14.3) 1 (4.8) 2 (9.5) 3 (14.3) Frozen Vegetables 4 (19.0) 5 (23.8) 7 (33.3) 2 (9.5) 0 3 (14.3) Starchy Vegetables 2 (9.5) 8 (38.1) 5 (23.8) 3 (14.3) 1 (4.8) 2 (9.5) Fresh Fruit 1 (4.8) 6 (28.6) 4 (19.0) 5 (23.8) 3 (14.3) 2 (9.5) Canned Fruit 2 (9.5) 10 (47.6) 5 (23.8) 2 (9.5) 0 2 (9.5) Frozen Fruit 7 (33.3) 4 (19.0) 3 (14.3) 3 (14.3) 1 (4.8) 3 (14.3) Refined Grains 3 (14.3) 7 (33.3) 2 (9.5) 3 (14.3) 3 (14.3) 3 (14.3) Enriched Grains 2 (9.5) 3 (14.3) 3 (14.3) 4 (19.0) 5 (23.8) 4 (19.0) Dairy 1 (4.8) 3 (14.3) 6 (28.6) 5 (23.8) 5 (23.8) 1 (4.8) a Frequency reported as n, parentheses indicate percent (%). Results of the estimated number of servings consumed from the listed food groups of respondents aged 60 years and younger are depicted in Table 5. The percentage of respondents aged 60 years and younger estimated to consume green vegetables were 43.6% (n = 17) and canned vegetables (33.3%, n = 13) once per day. Respondents were estimated to consume frozen vegetables once, 30.8% (n = 12) to twice, 30.8 (n = 12) a day, while starchy vegetables were estimated to be consumed by 25.6% (n = 10) of respondents either once, twice, or three times per day. Fresh fruits were consumed twice

50 50 per day by 25.6% (n = 10) of respondents. Thirteen (33.3%) respondents were estimated to consume canned fruits once per day, while 51.3% (n = 20) of respondents were estimated to never eat frozen fruit. Eleven (28.2%) respondents were estimated to consume refined grains once per day, while 25.6% (n = 10) of respondents were estimated to consume enriched grains three times per day. Nineteen (48.7%) respondents were estimated to consume dairy products four or more times per day by those 60 years and younger. Table 5 Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by those Younger than 60 Years Produce Never Once Twice Three Times Four or More Missing Green Vegetables 5 (12.8) a 17 (43.6) 11 (28.2) 3 (7.7) 3 (7.7) 0 Canned Vegetables 4 (10.3) 13 (33.3) 11 (28.2) 7 (17.9) 4 (10.3) 0 Frozen Vegetables 7 (17.9) 12 (30.8) 12 (30.8) 6 (15.4) 2 (5.1) 0 Starchy Vegetables 4 (10.3) 10 (25.6) 10 (25.6) 10 (25.6) 5 (12.8) 0 Fresh Fruit 8 (20.5) 9 (23.1) 10 (25.6) 7 (17.9) 4 (10.3) 1 (2.6) Canned Fruit 10 (25.6) 13 (33.3) 7 (17.9) 5 (12.8) 3 (7.7) 1 (2.6) Frozen Fruit 20 (51.3) 7 (17.9) 5 (12.8) 3 (7.7) 2 (5.1) 2 (5.1) Refined Grains 6 (15.4) 11 (28.2) 6 (15.4) 7 (17.9) 9 (23.1) 0 Enriched Grains 8 (20.5) 6 (15.4) 8 (20.5) 10 (25.6) 7 (17.9) 0 Dairy 4 (10.3) 4 (10.3) 2 (5.1) 10 (25.6) 19 (48.7) 0 a Frequency reported as n, parenthesis indicate percent (%)

51 51 Results of the estimated number of servings from the listed food groups of married respondents with children under 18 years are depicted in Table 6. Twelve (44.4%) respondents were estimated to consume green vegetables once per day; similarly 44.4% (n = 12) of respondents were estimated to consume frozen vegetables twice per day. Nine (33.3%) respondents were estimated to consume starchy vegetables twice per day as well. It was estimated that canned vegetables were consumed once per day by 48.1% (n = 13) of respondents. Fresh fruits were consumed twice per day by 29.6% (n = 8) of respondents. Canned fruits were estimated as being consumed once or twice per day by 29.6% (n = 8) of respondents. However, frozen fruits were estimated as never being consumed by 40.7% (n = 11) of respondents. Eleven (40.7%) of respondents were estimated to consume refined grains once per day, while 33.3% (n = 9) of respondents were estimated to consume three servings per day of enriched grains. Finally, dairy products were estimated as being consumed four or more times per day by 33.3% (n = 9) of married respondents.

52 52 Table 6 Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by Married Parents Produce Never Once Twice Three Times Four or More Missing Green Vegetables 4 (14.8) a 12 (44.4) 6 (22.2) 2 (7.4) 2 (7.4) 1 (3.7) Canned Vegetables 1 (3.7) 13 (48.1) 6 (22.2) 2 (7.4) 4 (14.8) 1 (3.7) Frozen Vegetables 5 (18.5) 7 (25.9) 12 (44.4) 2 (7.4) 0 1 (3.7) Starchy Vegetables 2 (7.4) 7 (25.9) 9 (33.3) 6 (22.2) 2 (7.4) 1 (3.7) Fresh Fruit 5 (18.5) 6 (22.2) 8 (29.6) 3 (11.1) 3 (11.1) 2 (7.4) Canned Fruit 6 (22.2) 8 (29.6) 8 (29.6) 3 (11.1) 1 (3.7) 1 (3.7) Frozen Fruit 11 (40.7) 5 (18.5) 4 (14.8) 1 (3.7) 2 (7.4) 4 (14.8) Refined Grains 2 (7.4) 11 (40.7) 2 (7.4) 6 (22.2) 5 (18.5) 1 (3.7) Enriched Grains 4 (14.8) 3 (11.1) 5 (18.5) 9 (33.3) 3 (11.1) 3 (11.1) Dairy 2 (7.4) 4 (14.8) 4 (14.8) 7 (25.9) 9 (33.3) 1 (3.7) a Frequency reported as n, parenthesis indicate percent (%) The estimation of servings consumed per day for single parents with children under 18 years are depicted in Table 7. Green vegetables were estimated as being consumed once per day by 48.5% (n = 16) of the respondents; similarly, canned, frozen, and starchy vegetables were estimated as being consumed once per day by 33.3% (n = 11), 30.3% (n = 10), and 33.3% (n = 11) of respondents. Fresh fruits were estimated as being consumed once or three times per day by 27.3% (n = 9) of respondents, while canned fruits were estimated as being consumed once per day by 45.5% (n = 15), and

53 53 frozen fruits were estimated as never being consumed by 48.5% (n = 16) of respondents. Seven (21.2%) of respondents reported consuming refined grains in the categories of never, once, and more than four times per day. However, 27.3% (n = 9) of respondents were estimated to consume more than four servings of enriched grains per day. Finally, 45.5% (n = 15) of the single parent respondents were estimated to consume more than four servings of dairy per day. Table 7 Frequency of Responses to Survey Questions Regarding Number of Servings of Vegetables, Fruit, Dairy, and Grain Consumed on Average per Day by Single Parents Produce Never Once Twice Three Times Four or More Missing Green Vegetables 1 (3.0) a 16 (48.5) 12 (36.4) 3 (9.1) 1 (3.0) 0 Canned Vegetables 4 (12.1) 11 (33.3) 8 (24.2) 6 (18.2) 2 (6.1) 2 (6.1) Frozen Vegetables 6 (18.2) 10 (30.3) 7 (21.2) 6 (18.2) 2 (6.1) 2 (6.1) Starchy Vegetables 4 (12.1) 11 (33.3) 6 (18.2) 7 (21.1) 4 (12.1) 1 (3.0) Fresh Fruit 4 (12.1) 9 (27.3) 6 (18.2) 9 (27.3) 4 (12.1) 1 (3.0) Canned Fruit 6 (18.2) 15 (45.5) 4 (12.1) 4 (12.1) 2 (6.1) 2 (6.1) Frozen Fruit 16 (48.5) 6 (18.2) 4 (12.1) 5 (15.2) 1 (3.0) 1 (3.0) Refined Grains 7 (21.2) 7 (21.2) 6 (18.2) 4 (12.1) 7 (21.1) 2 (6.1) Enriched Grains 6 (18.2) 6 (18.2) 6 (18.2) 5 (15.2) 9 (27.3) 1 (3.0) Dairy 3 (9.1) 3 (9.1) 4 (12.1) 8 (24.2) 15 (45.5) 0 a Frequency reported as n, parenthesis indicate percent (%)

54 54 Transportation Access and Grocery Store Food Purchases In order to provide insight of the sample population s access to transportation, respondents were asked to indicate the agreement or disagreement with nine survey items that related to transportation, including transportation costs, reliable vehicle access, travel distances, and difficulties with transportation (See Appendix E for data). Respondents strongly agreed, 50.8% (n = 30) with the statement that cost of transportation to grocery stores influenced food purchases. However, 31.6% (n = 19) of respondents strongly agreed to traveling to grocery stores that were further away due to lower food prices. In order to obtain more information on respondents views of transportation costs, respondents were asked if cost of travel did or did not influence where grocery shopping was performed. Results indicated that 42.4% (n = 25) of respondents strongly agreed with the statement of cost of travel does influence where I go grocery shopping, while 26.3% (n = 15) of respondents strongly disagreed with the statement cost of travel does not influence where I go grocery shopping. The statement I need to budget for gas when grocery shopping for food was strongly agreed by 44.8% (n = 26) of the respondents. Finally, 42.4% (n = 25) of respondents strongly agreed with the statement of I have access to a vehicle all of the time, while 8.5% (n = 5) of respondents strongly disagreed with the statement.

55 55 Of particular interest was the survey item I have chosen not to go grocery shopping because of the cost it takes to get there. Figure 1 indicates that the most common response for the statement I choose not to go grocery shopping because of the costs to get there, was the category of neither agree or disagree which comprised 39.3% (n = 22) of total survey respondents followed by the response of strongly disagree, 30% (n = 18). Figure 1. Frequency of choosing not to go grocery shopping because of costs as reported by participants.