5

Individual and Family Coping Responses to Hunger

The workshop’s third session focused on coping strategies used by individuals and households when faced with food insecurity or hunger. The speakers provided an overview of what is currently known and not known about strategies households use to cope with food insecurity and hunger and focused on identifying what they see as the most important research questions and data needs going forward. The moderator was Sonya Jones, Department of Health Promotion, Education and Behavior, University of South Carolina, and the deputy director of the Center for Research and Nutrition and Health Disparities. The main speaker was Mariana Chilton, Drexel University School of Public Health, director of the Center for Hunger-Free Communities, co-investigator for Children’s HealthWatch, and founder of Witnesses to Hunger. The second scheduled speaker, Kathryn Edin of Harvard University, was unable to attend the workshop, but Sarah Zapolsky, social science research analyst with the U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS), presented the SNAP Food Security In-Depth Interview Study (Edin et al., 2013), a study Edin and Mathematica Policy Research conducted for FNS related to the Supplemental Nutrition Assistance Program (SNAP). The discussant was Colleen Heflin, Harry S Truman School of Public Affairs, University of Missouri.



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5 Individual and Family Coping Responses to Hunger T he workshop’s third session focused on coping strategies used by individuals and households when faced with food insecurity or hunger. The speakers provided an overview of what is currently known and not known about strategies households use to cope with food insecurity and hunger and focused on identifying what they see as the most important research questions and data needs going forward. The moderator was Sonya Jones, Department of Health Promotion, Education and Behavior, University of South Carolina, and the deputy director of the Center for Research and Nutrition and Health Disparities. The main speaker was Mariana Chilton, Drexel University School of Public Health, director of the Center for Hunger-Free Communities, co-investigator for Children’s HealthWatch, and founder of Witnesses to Hunger. The second scheduled speaker, Kathryn Edin of Harvard University, was unable to attend the workshop, but Sarah Zapolsky, social science research analyst with the U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS), presented the SNAP Food Security In-Depth Interview Study (Edin et al., 2013), a study Edin and Mathematica Policy Research con- ducted for FNS related to the Supplemental Nutrition Assistance Program (SNAP). The discussant was Colleen Heflin, Harry S Truman School of Public Affairs, University of Missouri. 43

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44 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER STATEMENT OF MARIANA CHILTON1 Chilton stated that she was tasked with talking about coping by indi­ viduals and families with a focus on what is known, what is not known, and topics for future research. Up-Front Concerns Chilton asked about distinguishing between child food insecurity (1 percent of households) and household food insecurity (21 percent of households), suggesting that the focus should be on all children who are exposed to food insecurity in the household. She observed that hunger is multidimensional as an economic, psychological, physical, social, and life- course experience. She said the food insecurity measure does not pick up the social issues or the dynamics of food insecurity across the lifespan that underlie food insecurity. She pointed out two unsettling areas related to food insecurity. The first has to do with the concept of parenting from two different perspectives: the research professional, who deals with theory, and the parent, who may deal with the actuality of food insecurity. The other is the unsettling nature of admitting that child hunger exists in the United States. Chilton briefly described the Witnesses to Hunger study (Chilton et al., 2009), a participatory action study ongoing in Philadelphia and now also in Baltimore, Boston, and Camden, New Jersey. Through this program, low-income women work with professionals to explore food insecurity and their interactions with federal safety net programs. The purpose is to make sure that they are participating in the national dia- logue on hunger and poverty, and are participating in the design, analysis, and dissemination of research. She pointed to what she called harmful assumptions that need to be dispelled. First, she said, it is tempting for professionals and researchers to think of parents who may be experiencing food insecurity as well- meaning, deserving, and dedicated to looking after their children. These are the parents who report on a survey that their children are very low food secure. It is unsettling to think about some parents as addicted to drugs and potentially self-medicating because of their experiences with trauma and depression. She went on to say that it is also unsettling to think about the context and the environments in which young children may be raised. She noted the individuals she describes may be called a hard-to-reach population, 1Chilton and colleagues prepared a commissioned background paper on this topic; see Chilton et al. (2013b).

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 45 and most current research methods cannot drill down to this level of detail. She stressed that what she described is not what is happening with all families experiencing very low food security at the household level. However, researchers should not be afraid to discuss drug addiction, vio- lence, and some negative environments in which children live. Witnesses to Hunger started in 2008 and has administered the House- hold Food Security Survey Module (HFSSM) several times. The group talks to women about why they may answer differently over time. Most of the women who experienced severe violence changed their responses concerning the depth and severity of food insecurity. When asked why, these women talked about how they often hid the true magnitude of food insecurity in their households because they were afraid the person asking the questions might report them to child services. They were afraid that their children would be taken away. She showed a photograph of a mother and her two children. The mother reported that “it makes me feel like less of a mom not to have food for my children.” Chilton concluded that the very act of asking the food insecurity questions challenges a respondent’s view of herself as a caring and provid- ing parent. Chilton said the safety net system is important to consider in a discus- sion about individual and household coping mechanisms. Although the safety net is supposed to be in place to protect children from experiencing hunger and food insecurity, she said the second unsettling thing about child hunger is that the public assistance systems are not reaching or working for the families and children who need them. She showed a photograph of a young child with his hand out- stretched. His mother took the photograph when they were applying for emergency food assistance. She had been cut off of Food Stamps because she had received a raise at her job, and she and her child were extremely hungry. In that moment, she said, he was reaching out to the caseworker who had a bag of potato chips. The mother ultimately did get the Food Stamps, but it meant child hunger and a challenging interaction with the system to do so. There are many layers to the system, and there should be increased attention given to how well they are working, Chilton urged. As another harmful assumption, Chilton noted food insecurity is considered to be an individual or family problem as explained by the measure in National Research Council (2006). She called this a harmful assumption because food insecurity does not happen in a vacuum. She said another harmful assumption is the distinction between deserving and undeserving poor. Researchers need to talk to people who are expe- riencing drug addiction, major mental health problems, and exposure to violence. She asked the audience about how to fight against the common misguided portrayal of people who are on SNAP benefits or who are on

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46 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER Temporary Assistance to Needy Families (TANF) and welfare as some- how “slumming the system.” She agreed that working families who are food insecure are important but said there is still a need to understand the dynamics of unemployment, disability, and other more difficult issues. Chilton said another harmful assumption is that hunger is a tempo- rary experience with temporary effects. She suggested that researchers look across generations and ask what happened during the childhoods of adults who have food-insecure children. She added that the assumption that food is the only thing that is going to fix the problem is also harmful. Finally, she said researchers and policy makers need to recognize that the safety net is not a single comprehensive program that works. What Is Known: Issues and Strategies Chilton went on to say that researchers understand that food insecu- rity is related to the concept of trade-offs.2 With not enough money in the household, a family has to make a trade-off among paying for rent, pay- ing for utilities, or paying for food (Frank et al., 2010; Rose, 1999). There is also a trade-off between being able to pay for prescriptions and paying for food (Bengle et al., 2010; Bukusuba et al., 2007; Seligman et al., 2010b). Research indicates that food insecurity is related to depression, social iso- lation, and anxiety. Depression and anxiety can exacerbate problems with parenting behaviors and with child development. Chilton showed another photograph taken by a participant in Wit- nesses to Hunger of a very dilapidated and messy kitchen without run- ning water or electricity in the house of a family experiencing very low food security. She said the image illustrates what happens when a family is housing insecure, energy insecure, and food insecure all at once. She said that researchers sometimes forget the magnitude of the problem and how difficult it is to raise a family in that environment. Chilton said that social networks can buffer families from food inse- curity, including sending a child to a neighbor’s house for dinner, relying on a grandparent, living with other people, or sharing resources (includ- ing Food Stamps) to feed the family. A social network can also make fami- lies more vulnerable, citing Hamelin et al. (2002), Martin et al. (2004), and Tarasuk (2001b), and noting many parents will eat less to minimize the effects of food insecurity on their children (Hamelin et al., 1999). Chilton said that another known issue is depression, but the causal pattern of depression is unknown. Children’s HealthWatch insists that depression and food insecurity cannot be separated. Researchers know 2These points are described more fully in the commissioned background paper (Chilton et al., 2013b:10).

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 47 about depression but may forget the real physical, emotional, and social pain that it can cause. Depression is very real, she emphasized, and can affect caregivers in profound ways (Black et al., 2012; Casey et al., 2004; W ­ hitaker et al., 2006). She went on to say that food insecurity is related to poor child health and well-being (Alaimo et al., 2001a, 2002; Cook et al., 2006, 2008). It is related to increased hospitalizations, poor child development, poor school performance, and suicidal ideation among children. However, what is for- gotten, she said, is a child’s illness affects the family’s balance and triggers coping mechanisms. When a child is sick, a parent takes off from work and loses wages. As a result, the family may lag behind on rent or ­ orrow b money, which makes them beholden to friends, family, a boyfriend or “sugar daddy,” often an older male figure with good financial income with whom a caregiver will live for a time. In this latter situation, there is an explicit understanding that for a month or two, that person will help support the family and buy food, but the relationship can put a woman in a very volatile situation, creating more risk and potentially more debt. For a very low-income family, a child’s illness can unleash particular cop- ing mechanisms that can place the family at much greater risk than simply losing a day of work. Emerging Knowledge Food insecurity is related to inconsistent or volatile income, violence in the family and in the community, and toxic stress, a topic of emerging research in child development. The idea is that early in childhood, if chil- dren experience severe and chronic stress and live in a situation where they cannot buffer themselves, this experience can have an effect on their ability to succeed in school, maintain a job, and earn a living wage later in life. Fram et al. (2011) also showed that children may have a strong sense of food insecurity in the household that may differ from what the parent reports on questionnaires. Chilton said that she found the conclusions in Coleman-Jensen (2011) are quite true in the Philadelphia neighborhoods where she works. Non­ standard work with unstable income and nonstandard work hours is related to food insecurity. Chilton said that nonstandard work is also related to “churning”: more income for a short period of time that causes a loss or reduction in benefits. But when the job ends, the household loses money and then must go back on public assistance. This on-and- off “churning” also creates more volatility and vulnerability to food insecurity. Chilton showed another photograph of a female participant in Wit- nesses to Hunger. She was working in a TANF Welfare-to-Work Program

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48 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER at the time and the papers that she had to file were shown in the photo- graph. She did not like her job, finding it depressing. She talked about being constantly hungry with a very low paycheck and that she had to decide whether she would be able to get to work (because she could not afford tokens to commute). She was wearing a sticker from the emergency room at Saint Christopher’s Hospital where Chilton does research. The woman told Chilton, “If I am not at work, I am usually in the emergency room because my kids are always so sick.” Chilton stated that researchers should try to understand the financial experiences of very low-income families. She called for a comprehensive study on how low-income families try to generate income and interact with financial services: conventional banking, alternative financial ser- vices (pawn shops, check cashing places), and family and friends. While researchers know a lot about the financial experiences of low-income families, she said they forget the depth of the problem, particularly when there is sickness in the family. She said the experience during the reces- sion, in which many people lost jobs or had their hours reduced, and experienced more substance abuse, robbery, and theft, increased issues related to very poor housing quality, frequent moves, homelessness, evic- tion, and alternative living arrangements. The situation is very complex, she said, stating that researchers think they understand the income sup- ports available for low-income families, but research is needed about the relationship of the dynamics of earned income to the dynamics of these income supports. She noted researchers tend to think only about official income, wages, and jobs. They do not think about job satisfaction, and they may or may not consider childcare. There are dynamics between wanting to go to school to improve the chances of earning a better wage, but needing to work in order to pay for food. It becomes a vicious cycle that some of the women in Witnesses to Hunger call the “monster under the bed.” She noted researchers rarely pay attention to shadow earned income. This income may be earned, but it is “under the table” though not neces- sarily illegal. It may not be reported on their taxes or to the caseworker overseeing their TANF benefits. Shadow jobs might not only include busi- nesses on the side doing hair and nails, childcare, and housekeeping, but also selling Food Stamps, doing sex work, selling drugs or being involved in the drug trade, relying on others who are in the drug trade, misreport- ing income, or stealing. She said a lot of underreporting of food insecurity occurs in surveys because of stacked questions that might be considered a probe about whether a family is using SNAP benefits to buy toiletries and supplies for the house. From a low-income family’s perspective, a lie protects themselves and their benefits, something researchers should be aware of.

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 49 She said that Weinreb et al. (2002) discussed the community child- hood hunger measure that was developed before the current household food insecurity measure was adopted. He noticed a relationship between severe child hunger and lifetime posttraumatic stress disorder among families experiencing major housing risk or homelessness. Melchior et al. (2009) also looked at the persistence of household food insecurity and how it is associated with the number of mental health problems and domestic violence. Chilton mentioned her new mixed-methods research (documented in Chilton et al., 2013a) on very low food security at the household level and its relationship to severe violence. Caregivers of young children reported about their own experiences from childhood through the present, using five different qualitative categories of exposure to violence, with short- lived violence, long-term violence, and life-changing (rape, sexual abuse, and severe neglect) violence as the most severe three. In these most severe three categories, the very low food-secure households had more than twice the exposure to violence of the low food-secure households. Toxic stress is defined as exposure to severe stress and/or hardship without adequate adult support (Shonkoff et al., 2012). It can include physical or emotional abuse, chronic neglect, the caregiver’s substance abuse or mental illness, exposure to violence, and also the accumulated burdens of family economic hardship. She said toxic stress affects the brain architecture and the organ systems of children, sometimes called allostatic load. So much stress on the body can increase risk for stress- related diseases and cognitive impairment. Children can be exposed to severe adverse events, but if they have good support, they are more likely to be able to avoid the worst outcomes. What Is Not Known Chilton said researchers do not know enough about the intergenera- tional transfer of hunger. They do not know how existing public systems work to protect or buffer children or whether they exacerbate child hun- ger. She suggested research on the foster care system and child welfare systems and how they interact with TANF, SNAP, and the Special Supple- mental Nutrition Program for Women, Infants, and Children (WIC). She suggested that researchers need to understand how Head Start is buffering young children, what is happening with childcare subsidies, and the USDA Child and Adult Care Food Program. She also called for more attention to family-focused public systems, noting that while there are administrative data and some investigations into churning, not enough is known about the dynamics of child hunger within the recertification time period, income volatility, and the concept of “working for peanuts.”

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50 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER She suggested research into the impact of categorical eligibility, the use of multiple programs, possible protections against child food i ­nsecurity by pairing the Low Income Home Energy Assistance Program (LIHEAP) with SNAP, housing subsidies, and pairing TANF and SNAP. Finally, she said more attention should be paid to employment: differ- ences across states, city wage structures, labor laws, paid sick leave, job stability, wages, and employment policies. Researchers consider public assistance programs, she said, but forget about income and the laws and policies that affect people’s incomes. Chilton showed a photograph of a broken telephone taken by one of the Witnesses to Hunger participants, who said, “This is how I think of the welfare office, because I don’t have a phone. This is the closest phone to me. They wrote me a letter and said call for appointment. How am I sup- posed to call for an appointment? If I do call them for an appointment, how are they supposed to call me back?” Chilton said Witnesses to Hunger has discussed shut-off notices with participants who do not realize they had been cut off of Food Stamps. She reported one person said, “I didn’t know that I was cut off of food stamps. I had a full basket of groceries that I was getting ready to buy. I had no food stamp money. I had to leave it all there and walk away. So I took this photograph of the empty cart to show you what that experience is like for me.” Chilton said that losing SNAP benefits, whether because of minor increases in income or administrative errors, can be harmful to the food security of children and families (Edin et al., 2013:23; Frank and C-SNAP Study Group, 2006; Gayman et al., 2010). Cook et al. (2002) found that when families reported being sanctioned (losing benefits) they had greater odds of reporting household food insecurity compared to families that had not been sanctioned. Chilton observed that this indicates there is something about SNAP, the income thresholds, and the administrative procedures that needs further attention. Research Priorities Chilton said research needs to be more policy and systems oriented. Research should consider multiple systems, not just food assistance, and how they work together, including wages and labor laws, TANF, housing subsidies, LIHEAP, and solution-oriented approaches. Chilton said a lot is known about the causes and consequences of food insecurity, and now is the time to start working with very large numbers of families through broad-scale interventions and demonstrations. If there is a relationship between disability and food insecurity, there should be research into the interaction between Supplemental Security Income and SNAP benefits, perhaps one state at a time.

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 51 She said that there is a great need for improvement of the language and the framing of child food insecurity and hunger to help clarify the concepts in discussions among researchers, the press, USDA, and policy makers. Enormous confusion exists among the concepts of food insecu- rity, low food security, and very low food security (see Chapter 2). The problem must be framed more clearly to communicate with legislators and the public about what is going on. Research, she said, should be multidisciplinary (epidemiology, eco- nomics, nutrition, sociology, anthropology, discourse analysis), using mixed-methods and longitudinal studies to include multiple generations. Finally, she said more research should be participatory (subjects as par- ticipants), because understanding the reality of food insecurity and child hunger requires directly talking and testing research ideas with people who have low income. STATEMENT OF SARAH ZAPOLSKY Zapolsky described research by Edin et al. (2013) that used the SNAP Food Security In-depth Interview Survey, a small component of the SNAP Food Security Study,3 noting the larger study results will be published shortly. The larger study was the largest survey of SNAP par- ticipants to date and was a longitudinal and cross-sectional combination. The survey consisted of two groups: 6,436 households that were just entering SNAP and 3,275 households that had been on SNAP for six or seven months. Both groups were asked a series of questions, including the HFSSM. Six months later, the same people were interviewed and asked questions, including those from the HFSSM. The study examined differences in food security between the two populations and differences between when they started and six months later. The SNAP Food Security In-depth Interviews were conducted between February and June 2012 with a subset of 90 SNAP households with children in about six states. The topics included financial situations, use of SNAP, overall food security, eating behaviors, nutritional atti- tudes, shopping behaviors, triggers of food hardship, and ongoing food strategies. Respondents were also asked about situations in which SNAP affected their overall food security. Interviews were held in the homes of respondents unless they preferred to meet in a public place like a library or coffee shop. Zapolsky acknowledged that this was not a probability sample of respondents, and so results do not generalize to any larger pop- ulation. Instead, the re-interview study is intended to provide insights. 3See http://www.fns.usda.gov/ora/MENU/Published/snap/SNAPPartOther.htm [­ ugust 13, 2013]. A

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52 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER One technique was an imaginary shopping trip in which the inter- viewer said, “Pretend you are going to the store. Where would you go first and what would you buy?” Each interview was transcribed and systemati- cally coded for themes. The authors systematically assessed whether there were especially large differences in general financial circumstances of food hardship and coping strategies, eating and food dynamics in the house- hold, and the role that SNAP plays in meeting a family’s nutritional needs by food security level and also by race/ethnicity. They observed almost no meaningful differences in coping factors by race/ethnicity and broke respondents’ coping strategies into two categories: reactive to deal with food hardships and proactive to avoid food hardships. Most respondents employed both. The most common proactive strategies observed were restricting food intake; altering types of food consumed; turning to net- works; visiting food pantries; and shopping modifications, such as scour- ing the ads for sales, traveling from store to store on multiple occasions, and planning meals exclusively around types of foods that were on sale. There were noted differences in coping strategies across food security levels. The least food secure were much more likely to say they had to restrict food intake to cope with the shortfall, which, based on the defini- tion of food insecurity, makes sense. However, a number of food-secure households reported in the in-person interview that they skipped meals so often that they considered the practice routine, which may indicate that food insecurity is underreported. For example, a mother said she never eats lunch, just drinking coffee available at work, or eats much less when her children are away. When asked if this counted as restricting meals, she replied, “No, this is what I do.” The most common coping strategy related to family networks. A sig- nificant minority of food-secure households with children take advantage of frequent invitations to relatives’ homes for meals and receive contribu- tions using cash from friends and family. Those households that can rely on their networks to provide cash or meals were most likely to be food secure near the end of the month when SNAP benefits run out. The study considered households with children and the three food security levels: secure, insecure, and very low insecure. Households with very low food security often explicitly stated that they do not have networks willing to help them. Those with very low food security but who had social ties said they cannot rely on these ties because their ties are usually in worse financial shape than the respondents and turn to the respondents as the contributors. Those who share their SNAP benefits with others were also clustered in the very low food security group, suggesting that when respondents extend charity to the even less fortunate, it is costly to their well-being. Strategies they said include shopping sales, using coupons, reducing the

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 53 number and quality of all meals or those of adults, and never entertaining or having people over, with birthday parties for the youngest children as the main exception. Respondents saw SNAP as a lifesaver, and they planned their budgets around it. It allowed parents to mostly protect their children from the worst of the food hardship, and it also allowed households to prevent hardships in other areas by using their cash for other bills. Many house- holds organize their budgets around the expectations that SNAP will suffice for the whole month, although the program is not designed to do that. Whether this is a planning issue is irrelevant because they did not have enough food. As Zapolsky explained, the one underlying factor that differed most among the different food security levels was that of access to family and social networks. All else being equal between two households, such as finances and demography, parents who can send their children to a rela- tive’s house for dinner are better off than those who have no such recourse. The flip side is that those who are donors for others are worse off. Zapolsky said Gundersen’s comment (see Chapter 3) about the pres- ence of older children in households being detrimental to food security reminded her of several conversations, such as “younger children are more welcomed to eat at a friend’s house than older kids,” or, worse, the “dreaded teenage male.” She said that respondents mentioned being clear with their older children about not bringing friends over around mealtimes or hiding food if they know that friends were going to come over. However, the strategy was often trumped by the pride taken in one’s cooking skills and the desire to make their children’s friends welcome. Zapolsky shared several observations. First, household rosters can be volatile. Normally, a survey asks about household composition on a typi- cal day. In this survey, respondents were asked about a specific day, such as yesterday or last Thursday, and were also asked very specific questions such as, “Who ate breakfast on Thursday?” Specific questions got specific answers. For example, the answer might be that “the uncle ate breakfast with us on Thursday.” The conversation might continue, “Tell me more about the uncle?” Followed by “Oh, he is visiting.” “How long has he been visiting?” “Six months.” There might also be a cousin who shows up at the first of the month or other visitors. As a result, FNS is considering alternative ways of asking about the household roster. Her second observation concerned respondents’ extreme and constant thought devoted to managing the household budget, procuring food, and making it last. She gave an example of the questions about the imaginary shopping trip. When asked about their stops in the grocery store, respon- dents typically said that they go first to the meat section for meat that will last a couple of meals. Next, they say that they select grains and rice, then

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54 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER milk and juice. Third, they get nonperishables that will last until the end of the month, with the rest of the shopping trip to stock up on perishables. Between this detail and respondents’ to-the-penny knowledge of costs, debts, and SNAP benefits, it is not a lack of education about financial man- agement, she said, but rather that there is not enough money to manage. Her third observation was about measurement and a need for further research. The less acculturated or Spanish speakers who were interviewed might answer affirmatively to all of the HFSSM questions. However, they would reply no when asked “Are you hungry? Have you experienced hunger?” This led the study authors to wonder about differing percep- tions or a stigma to reporting hunger in this population. STATEMENT OF COLLEEN HEFLIN Heflin described what is known and needs to be known about two areas integral to understanding how households cope with food insecu- rity: (1) the trade-offs that households make with other essential needs, and (2) participation in food and assistance programs with a focus on the issue of nonparticipation. While the workshop focused on the issue of childhood hunger and food insecurity, households that report childhood hunger are also likely to be in dire financial straits and are facing shortages of other essential needs, she noted. Households will go to tremendous efforts to shield children from food insecurity, and those that are reporting childhood food insecurity are unable to cut from any place else, which means they are likely experiencing trade-offs in other essential areas. They could be pay- ing less than their full amount of rent or mortgage, or they are living in poor-quality housing. They may be facing utility cut-offs, or at least they are not paying their full rent or utilities, and they are juggling essential bills. Finally, they may forgo medical care or prescriptions and may be facing transportation needs. Heflin said that Edin et al. (2013) reported that a respondent talked about not going to church as often to save money for food. In other cases, transportation needs are a trigger for households. When households are faced with having to fix a vehicle, they will take that money from their food budget if they have nowhere else to take it from. When talking about child hunger, Heflin pointed to a broader picture of other essential needs also not being met. She highlighted results from a Missouri food pantry clients survey (Vancil et al., 2013), conducted in 2010, in which 42 percent of clients reported that they had to choose between buying needed food and paying for medicine or medical care. Forty-six percent reported trading off between buying food and paying for utilities, 56 percent reported trading off between buying food and

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 55 paying for rent or mortgage, and 60 percent reported trading off between buying food and paying for gas. Only one-quarter did not report any of these trade-offs, while another one-quarter reported making trade-offs in all four areas within the last year. Food insecurity implicitly means other material needs are not being met, she stressed. She referred to work with colleagues (Heflin et al., 2009) in which they used the Urban Change Data, an ethnographic study done in the early 2000s, and considered unique aspects of food insecurity that impact how households cope with food insecurity versus other types of material needs. She noted food consump- tion is very sensitive to income fluctuations because a small amount of money may be all that is required to improve or worsen the experience of food hardship, in contrast to some other types of material hardship, like housing or utilities, with higher thresholds. Perhaps as a result of this low threshold for remediation, food hardship is often experienced over a very short time frame. The qualitative reports make it clear that food insecurity is often experienced just for one or two days at the end of the food stamp cycle. Second, she explained, food needs are recurrent because food supplies are not durable like clothing. In addition, unlike utilities paid monthly, there is a continual need to keep the food sup- ply adequate, which is problematic because demand fluctuates over the month. Households expand to include both short- and long-term visitors, making it difficult to plan and optimize. Finally, unlike housing and util- ity hardships, food hardships are not uniformly experienced within the household. Adults cut back in order to shield their children. Given that food-insecure households are likely to be experiencing other forms of material hardship, Heflin described the need for a nation- ally representative dataset that contains measures of food security as well as other forms of material hardship. Currently, the Current Population Survey with the HFSSM is the gold standard to look at food security data, she noted, while the Survey of Income and Program Participation (SIPP) is the standard for nationally representative data on other forms of material hardship, as found in the Adult Well-being topic module. Only 5 of the 18 questions from the HFSSM are included in the SIPP, making it difficult to analyze how food security and other forms of material hardship exist together in a quantitative, nationally representative sample. She said given the high co-morbidity among these conditions, researchers are likely ascribing some of the consequences to food secu- rity that may be due to other types of hardship, or combinations of hard- ships. When trying to understand how people cope with food insecurity, she said it does not make sense to ignore these other forms of material hardships. To some extent, she said, the issue is that different government agencies manage different programs, which ignores the holistic experi- ence of children and the households in which they live.

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56 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER Heflin suggested that the Healthy, Hunger-Free Kids Act may pro- vide an opportunity to think about childhood well-being more broadly. She proposed that to better devise strategies to address food insecurity, researchers and policy makers need to know more about where food fits in a family’s list of priorities of essential needs and how this prioritization process differs across families. What rules do families use to decide which trade-off to make when they are faced with scarce financial resources? Heflin stated that it is important to understand the optimization process and how the process differs with specific family situations. Examples of specific situations include very high medical needs, violence issues, and drug and alcohol dependence, where families may actually be optimizing something else besides their food security. Heflin acknowledged the work described by Edin and Lein (1997) on food and family budgets, saying that data on family expenditures and resources that could be related to all forms of maternal hardship would help researchers understand how families are prioritizing. Nonparticipation Heflin stated that participation in federal food assistance programs is often the main way for food-insecure households to cope, and nonpartici- pation rates among eligible households vary by program. Cunnyngham et al. (2013) reported that 75 percent of eligible households participate in SNAP. Tiehan and Jacknowitz (2010) reported that 79 percent of eligible households participate in WIC, at least in the first year, when the children are between birth and one year old. Dahl and Scholz (2011) reported that 75 percent of eligible households are participating in the National School Lunch Program and about 50 percent of eligible households participate in the School Breakfast Program. Heflin noted participation in SNAP increased from 54 percent in 2002–2003 to 72 percent in 2009–2012, noting variation over time. She showed a map of participation rates by state (see Figure 5-1). For example, Oregon’s SNAP participation rate is close to 100 percent of eligible par- ticipants. However, in Florida the participation rate is about 60 percent. Heflin noted that American Recovery and Reinvestment Act of 2009 (P.L. 111-5) incentive funds and caseload pressures have induced states to changing their administrative procedures, and these processes might influence participation rates. She said that the food stamp application process is usually thought of as involving a paper application, a wait in an office, and interaction with a caseworker; however, many states, including Florida, use an online application. If applicants have ques- tions, they call a call center, and the eligibility interview takes place over

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 57 State SNAP Participation Rates: FY 2009 WA ME MT ND OR MN VT NH WI NY ID MA SD MI RI WY CT IA PA NJ NE DE NV OH IL IN UT CA CO WV KS VA DC MO MD KY NC TN AZ OK NM AR SC MS AL GA LA TX HI AK FL 2009 Participation Rate for All Eligible People Above 82% (top quarter) 70% to 82% Below 70% (bottom quarter) National Rate = 72% FIGURE 5-1  State SNAP participation rates, FY 2009. SOURCE: U.S. Department of Agriculture, Food and Nutrition Service (2012a:15). Reprinted with permission. Figure 5-1 the phone. It is important for researchers to be aware of which groups are going to be able to negotiate this process and which are not, she said. Heflin stated that based on her work in Florida, this application pro- cess is very easy for the working poor to negotiate and it probably benefits them as they do not have to take time off of work. However, other groups, such as the elderly, the disabled, and those with language or computer lit- eracy issues, may have a much harder time negotiating this modern appli- cation process. States are modernizing, and Heflin suggested that FNS and the research community take a close look at the application process to determine what the drive to efficiency is doing to program accessibility. Finally, she stressed the importance of considering how cultural fac- tors and stigma might be influencing participation rates. Heflin reported that she and colleagues have done some work contrasting the application processes in Florida and Oregon.4 She said in Oregon, there is a sense of participation in SNAP as a right and almost a responsibility. The governor 4A paper on this research has been submitted for publication and is in review: C. Heflin, P. Mueser, S. Porter, and B. Weber, The Great Recession and SNAP caseloads: A tale of two states.

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58 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER took the food stamp challenge (to purchase food within SNAP limits) and convened a hunger task force. There is a sense in Oregon that the relevant social service agency is organized to make participation as easy as pos- sible for all eligible participants. In contrast, she noted, hunger advocates describe a general attitude in Florida that SNAP participants are indi- viduals who are basically lacking personal responsibility. The difference between 100 percent participation in Oregon and the 60 some percent in Florida is not a surprise, she noted. She suggested that political factors and the role of nonprofit groups and hunger advocacy groups in shaping the culture of participation should receive more attention. Heflin had two suggestions about the structure of future research opportunities. First, she supported continuation of small grants pro- grams, similar to the one at the University of Kentucky Center for Poverty ­ Research. She said small grants are particularly effective to expand the pool of researchers doing work in this area, attracting the attention of researchers who want to tentatively take a look at the field. Increasing the pool of researchers will increase the number of new ideas. Her second suggestion was to encourage an interdisciplinary approach because an analysis of childhood hunger and food insecurity involves economic decision making and social processes with nutritional health and developmental consequences that are structured by political, eco- nomic, and social factors. This definition includes a need for ­ esearchers r in the areas of economics, sociology, public health, social work, family studies, and medicine, she said. OPEN DISCUSSION Rafael Pérez-Escamilla (Yale University) said that the research studies on coping behaviors summarized by the speakers are examples of what he would term negative or harmful coping behaviors. He asked about work on positive deviance to try to understand how food-secure households living under similar conditions of poverty cope with the condition in a more positive way. Chilton noted Heflin’s reference to participation in public assistance programs as a coping mechanism, saying she does not view participation as a negative. Rather, she said, people are working to get involved with a system meant to help them. She suggested that a positive deviance might be having a small business on the side, such as doing hair and nails, pro- viding childcare, or housekeeping, although, she noted, the current sys- tem criminalizes even that kind of activity. She said selling food stamps could be considered a form of positive deviance; however, it is currently criminalized, and acknowledged that talking about it in front of the audi- ence makes many people very nervous. She suggested that language, the

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 59 way research questions are framed, and fear of discussing certain issues gets in the way of researchers looking at many of these coping behaviors in a more positive light. Mark Nord (Economic Research Service) praised the example of Oregon and its near 100 percent participation rate of eligible persons in SNAP. He said that before the food insecurity measure became common, the participation rate in ­ regon was about median for the country. In the O first years of the measure, Oregon had the highest rate of what is now called very low food security. Governor Ted Kulongoski (2003–2011) ran partly on a platform of doing something about food insecurity. Oregon provides strong evidence that states can improve both food security and participation in programs, and he characterized Oregon as the “poster child” for the value of monitoring. Nord said more quantitative information about the picture from Wit- nesses to Hunger would be helpful. He called it an extremely important picture, but understanding how many households face the conditions described by the project would help develop interventions. Although he called the participants’ situations discouraging, he said it is clear that there is a broad spectrum of needs to be addressed. He pointed out that the proportions of households reporting very low food security over the entire five-year period of the Early Childhood L ­ ongitudinal Study-Kindergarten Cohort was exceedingly small. Bartfeld and Ahn (2011) suggested that an extreme, persistent multi­ enerational g problem may only be a small piece of the puzzle, although he remains uncertain. He asked about a way to gain perspective on where the types of households Chilton described fit into the whole. Chilton said photographs from Witnesses to Hunger help to bring to light the severity of the issues, but they bring to light only a certain pro- portion, and it is hard to know the magnitude. She said this uncertainty points to the need for mixed-methods research. She said that it is also time to look into the child welfare system, tracking food insecurity among foster children or children in the child welfare system. Perhaps questions about drug addiction and exposure to violence need to be added to quan- titative studies, she suggested, to start understanding the magnitude of the problem. She said, in her opinion, it is practically impossible to take the methodology of Witnesses to Hunger to scale, although there may be a way to bring quantitative measures into the program by inserting some measures about exposure to violence and drug addiction. Edward Frongillo (University of South Carolina) stated that he was glad to hear about the in-depth studies with SNAP participants. He referred to Zapolsky’s comment that in a face-to-face interview, people are willing to admit to a problem if responses on questionnaire items are reversed over time. He reported when he first started doing in-depth

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60 CAUSES AND CONSEQUENCES OF CHILD FOOD INSECURITY AND HUNGER interviews about food insecurity with older people in the 1990s, he found them very willing to tell their stories, which enabled the researcher to determine whether or not they were food insecure, to what extent, and what it meant. Respondents would not directly say that they were food insecure, yet, they would still tell their stories. This made researchers wonder about the quality of follow-ups done via telephone. He noted some critical points made by Chilton and Heflin. Con- text really matters. If people think they are going to lose something by responding affirmatively, for example losing their children or benefits, then, of course, that will affect their response. He noted the older people he interviewed in upstate New York who had grown up in the South with very challenging experiences had very different views about what was normative. Those life experiences influ- enced the way they talked about things. As Chilton observed, it is impor- tant to think through the implications of a long-term history of material deprivation. Joel Berg (New York City Coalition Against Hunger) said in New York City, SNAP caseloads increased by 1.1 million in the last decade and cash assistance caseloads have declined by 100,000. As a result, he said, 1.3 million people just in New York City are now getting SNAP who also warrant cash assistance. He stated that individuals may “waste” cash assistance on rent, but some of them use it on food. He asked the speakers if they were aware of research on the link between reductions in TANF and food insecurity during the last decade, and if not, whether they see it as a useful area to look into. Chilton said that Children’s HealthWatch (formerly the Children’s Sentinel Nutritional Assessment Program) had a publication on the impact of TANF sanctions on the health and well-being of young children (Cook et al., 2002). It was observed that if a family was sanctioned off of TANF for failure to comply, their risk of hospitalizations increased. She noted that Gayman et al. (2010) looked at reports of increased income, subsequent loss of TANF benefits, and the association with child hunger. Chilton said that she thinks a very strong relationship between loss of TANF benefits and food insecurity exists, and agreed with a need for more research. Heflin cited information in Kalil et al. (2002), based on the Women’s Employment Survey, as well as information in Lindhorst and Mancoste (2006) from Fragile Families. Most of the research looks at sanctions, but some also look at the TANF population for surveys that were constructed in the late 1990s and early 2000s that are still ongoing. Jasbir Sangha (National Center for Health Statistics/Centers for Dis- ease Control and Prevention) said that Chilton’s case studies reminded her of her experience 18 years ago as a WIC nutritionist in Philadelphia. One participant who was taking care of foster children was clearly on drugs.

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INDIVIDUAL AND FAMILY COPING RESPONSES TO HUNGER 61 She said that as the system dictated, they gave this woman food packages, but said she remembers feeling that if the woman could afford drugs, she could afford food. She said at the time she was not aware of the multi­ generational effect and did not mean to diminish the importance of safety nets like WIC. The words that resonate with her in this workshop session, she commented, related to violence, drugs, and alcohol and asked how the food security research community can address these issues. Though they may be root causes of food insecurity, some of these issues seem to be beyond the scope of food insecurity researchers. Chilton acknowledged the complexity and the struggle about pro- viding the WIC food package when the participant may buy drugs. She asked the audience to think about why the woman might be using drugs, suggesting she might be self-medicating from past exposure to trauma or sexual violence. If she is not given the food package, what other kind of risks is the program exposing her to? A number of states are making efforts to require people who are signing up for SNAP benefits to undergo drug tests. If they test positive, then they would not be able to receive the benefits. But, she said, no discussion is under way about whether people struggling with addiction might need help, and no effort to help them. She suggested the need to rethink the relationship between SNAP and WIC and other subsidies, suggesting that the subsidies might be a way to encourage families to come into the system and then find them more help. She said WIC has done a good job in several states integrating domestic violence counseling into the WIC offices and expressed support to providing food and nutrition education and helping hook people into other services. Chilton mentioned also that WIC is associated with reduc- ing stress (Black et al., 2012). She closed by saying the system needs to recognize that when people are extremely poor, using drugs, or experiencing drug addiction, a long line of offences and violations to their dignity and health and safety need to be taken into account. They should not be judged in the moment for smoking or using alcohol. She said care is needed in framing research. Much research is needed into the impact of exposures to severe violence and to severe poverty at the same time during early childhood. She sug- gested focusing on early childhood might be the “clincher” to solve this problem.