Using the Transtheoretical Model of Change to motivate SNAP-eligible adults toward application

1 Using the Transtheoretical Model of Change to motivate SNAP-eligible adults toward application Carolyn Bird, Jeanette Maatouk, Amy Pipas, Nancy Abasiekong, Haylely Napier, & Deborah McGiffiin North Carolina State University/North Carolina Cooperative Extension Background The Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program) is a federal nutrition program designed to prevent food insecurity and reduce poverty through helping low-income individuals and families access a nutritious diet. SNAP, which currently reaches over 47 million people, provides a monthly benefit to individuals and families based on income, size of the household, and certain household expenses. SNAP is provided each month and offers a consistent means to supplement food purchases for a household (USDA 2012). The average monthly benefit for an individual is around $133 or nearly $1,600 per year (USDA 2013). Many assistance programs have specific eligibility requirements related to age (Supplemental Security Income), family composition (Temporary Assistance to Needy Families), or employment status (Unemployment Insurance). SNAP is different because most households that meet income requirements can receive benefits. SNAP serves a wide range of people including children, older adults, unemployed adults, working families, and people with disabilities (USDA, 2012). Even with broad eligibility requirements, many people that are eligible for SNAP are not receiving benefits. It s estimated that overall SNAP reaches only 75% of eligible people and participation varies widely among subgroups. For example, participation rates among the working poor and older adult

2 populations are lower than average, with SNAP reaching 65% and 35%, respectively (Mathematica, 2012). A person may decide not to participate in SNAP for many reasons, but the most common reasons for non-participation include: lack of information about eligibility, dissatisfaction with the size of the benefit, a sense that benefits are not needed, stigma associated with participation, and perceived or actual complexity of the application process (USDA, 2012). The USDA instituted SNAP-Outreach grants to address and reduce barriers to participation with the goal of facilitating SNAP enrollment to increase the number of eligible people receiving nutrition assistance. This paper describes a SNAP-Outreach program developed by North Carolina State University and administered through North Carolina Cooperative Extension. The target audience, projected outcomes, program components, and impacts will be discussed. Purpose More In My Basket (MIMB) is a Supplemental Nutrition Assistance Program (SNAP)- Outreach project developed by North Carolina State University and administered through North Carolina Cooperative Extension. MIMB goals are that participants: will have increased knowledge (Preparation stage) about the SNAP program will apply (Action stage) for SNAP if they are eligible and not already receiving benefits. MIMB employs the Transtheoretical Stages of Change (Prochaska, DiClemente, & Norcross, 1992; Prochaska & DiClemente, 1983) to reduce barriers to SNAP participation by promoting participant progression from early stages of change (Precontemplation, Contemplation, or Preparation) to the stage of Action. MIMB accomplishes its goals

3 through community education and facilitating access to benefits through application assistance. MIMB targets all likely SNAP-eligible North Carolina adults. There are approximately 1.7 million SNAP-eligible individuals in North Carolina, of which 78% are enrolled. Thus, there are nearly 133,000 SNAP eligible individuals that are not participating in the program (Mathematica, 2012). Overview MIMB Program Description The MIMB program is delivered by county-based Cooperative Extension agents. To maximize program outreach the curriculum includes three different delivery formats (McClelland & Bird, in press): group presentations, individual consultation meetings, and booth-based outreach. Group presentations last approximately 45 minutes to 1 hour, and are usually conducted for groups with less than 30 participants. Individual consultation meetings are generally conducted in conjunction with Medicare Part D enrollments. Boothbased outreach targets larger audiences, with events, such as health fairs, reaching up to 1,000 participants. MIMB addresses multiple barriers to SNAP participation. For example, one common barrier to participation is that people anticipate receiving a minimum $16 per month benefit and indicate that it is not worth the effort to apply. MIMB addresses this myth on two levels: cognitive and emotional. The first three TTM stages of change relate to cognitive processes; cognitive elements address what people think, remember, or how they reason. MIMB draws on historical North Carolina data to show that while $16 per month is the minimum, the average benefits for adults are much higher approximately $135 for all adults, and $87 for older adults. Thus, participants are enlightened to the fact that they

4 may have lacked accurate information or their thoughts or reasoning about their anticipated benefit level may have been incorrect. Secondly, MIMB appeals to emotion by generating excitement about the impact that even the $16 per month minimum can have on monthly and annual food purchases. Colorful food photos make a visual impact on participants and create an emotional connection as the Cooperative Extension agent illustrates the amount of food that can be purchased at three levels of benefits: 1) at the minimum, ($16/month), 2) at the average for older adults ($87/month), and 3) at the average for all adults ($135/month). These demonstrations surprise the participants and generally leave them interested in seeing if they qualify. Having dispelled myths MIMB encourages participants to take action by participating in its eligibility screening and SNAP application completion assistance services, thus addressing the barrier of application process complexity. MIMB program staff provide screenings and application assistance either on-site in conjunction with agentled community programs or from the State office through a toll-free number provided to participants. MIMB staff walk participants through the application process using webbased software and provide instruction on how to submit the application to the Department of Social Services for final determination of eligibility. These are just two examples of MIMB s response to barriers to SNAP participation. The table below shows how MIMB addresses other common barriers. Table 1 MIMB Program Components Address SNAP Barriers Barriers to SNAP Participation Lack of information about MIMB Program Components Participants learn about basic eligibility requirements, income guidelines, assets, and deductions.

5 eligibility Eligibility screenings offered using The Benefit Bank software (Ref?). Screenings conducted on-site or via toll-free number. Dissatisfaction with size of the benefit Lack of understanding the value of the benefits to household economy Stigma associated with participating Complexity of application process Curriculum uses colorful, inviting food photographs to demonstrate the positive impact benefits can have on a family s grocery budget. Consumers learn that even the minimum benefits can make a big difference in the amount of food their family will have. Participants learn how additional food benefits can free up money to pay for other expenses, like medical or utility costs. Benefits of using EBT are explained. Eligible food items as well as seeds and plants used to grow food are discussed. Participants learn about the Electronic Benefit Transfer (EBT) Card, which is used to make SNAP purchases. This replaced the tear-off food stamps, and is used like a debit/credit card. Consumer impact stories shared to show that how SNAP has helped others in similar situations. Toll-free line offers participants an anonymous way to ask questions and receive assistance. Application process explained. Application assistance offered using The Benefit Bank software. Convenient assistance either on-site or via toll-free number. Activities During MIMB s Federal Fiscal Year 2013 (October 1, 2012 September 30, 2013) program, 38 North Carolina counties delivered the MIMB program and performed outreach to 2,839 participants over a 9-month period. Of the 63 MIMB programs offered group presentations was the most common type of outreach event. Even so, the majority of participants (81%) were reached through booth-based outreach at large scale events, which is expected because booth-based events tend to reach larger crowds, with one event reaching 1,000 people. The table below shows by program format the number of people reached through MIMB outreach programs.

6 Table 2 MIMB Participation by Session Format Format # Programs Conducted # Participants Reached Group 36 533 (18.77%) Booth 23 2,300 (81.01%) Individual Consultation 4 6 (.21%) Total 63 2,839 MIMB programs were conducted in a wide variety of community settings, including: senior centers, low-income and senior housing communities, congregate nutrition sites, workplace wellness fairs, senior expos, and faith-based groups. Agents also presented MIMB in conjunction with other Cooperative Extension groups, such as Extension and Community Association meetings, Grandparents Raising Grandchildren get-togethers, and Aging with Gusto! conferences. Demographics Evaluation forms included demographic data and were tailored to each outreach program format (McClelland & Bird, in press). Specifically, limited information was collected from participants at booth presentations and at individual consultations due to considerations such as brief time of interaction and/or privacy concerns. Group presentations offered the most suitable venue for surveys that included demographic information. Of the people who provided complete demographic information, the majority were female (79.4%) and older adults, age 60 or over (72%). The high representation of older adults reflects strong outreach efforts at senior centers, senior expos, and congregate nutrition sites and is reflective of MIMB s inaugural approach of focusing on the older adult population. The SNAP participation rate among older adults is very low (35%) (Mathematica, 2012), so there is a need for continued outreach to this group. Over half

7 (51.8%) of participants were Black/African American and 38.8% were White. Only 2.3% of participants were Hispanic or Latino. Most participants lived in small households, with 60.5% living alone and 24.4% living in a two-person household. Table 3 Participant Demographics Gender Number Percentage Male 84 20.36% Female 324 79.4% Age Number Percentage 39 or younger 60 9.3% 40 59 120 18.7% 60 79 362 56.4% 80 or older 100 15.6% Race Number Percentage White 132 38.8% Black/African American 176 51.8% American Indian/Alaska Native 23 6.8% Asian 2.6% Other 7 2.1% Ethnicity Number Percentage Non-Hispanic or Latino 203 97.6% Hispanic or Latino 5 2.3% Household Size Number Percentage 1 176 60.5% 2 71 24.4% 3 28 9.6% 4 or more 16 5.3% Monthly Net Income Number Percentage Less than $931 89 33.8% $932-$1,261 66 25.1% $1,262-$1,591 39 14.8% $11,592-$1,921 24 9.1% $1,922-$2,251 12 4.6% $2,252 or more 33 12.5% Poverty and Hunger Conditions Of the individuals who reported both household size and net income, 41.93% (91) had incomes below the poverty line and would likely qualify for SNAP benefits. Respondent

8 surveys showed evidence of being food insecure over the past 12 months: 13.4% (47) skipped meals because of costs, 21.9% (77) cut the size of meals because of costs, and 10.2% (36) felt hungry because they couldn t afford food. Participants reported making other financial decisions, including: 12.5% (44) didn t see a doctor because of costs, 14.2% (50) skipped medication because of costs, and 15.9% (56) spent less on food or heat to pay for health care or medications. SNAP Knowledge Impacts Results During the program year, 2,839 people in 38 North Carolina counties received education and SNAP enrollment support through the MIMB program. Pre- and postprogram evaluation surveys measuring knowledge change about SNAP were administered to 533 people reached through group sessions and 428 provided complete data. Participants demonstrated positive knowledge change on all questions with the greatest changes (Table 4) related to learning how and where to apply for SNAP (Q2) and learning how to receive assistance with the application (Q4). Table 4 Group Survey Reponses - SNAP Knowledge Survey Question Pre-Test Post-Test Change 1. I know how even an extra $16/month can buy more health 79.9% 92.3% +12.4 foods. 2. I know how and where to apply for SNAP benefits. 50.6% 81.6% +31 3. I know how EBT cards and benefits work. 54.7% 83% +28.3 4. I know how to receive assistance with the SNAP application. 48% 83.2% +35.2 5. People that have assets or resources 59.4% 88% +28.6

9 can still qualify for SNAP benefits. SNAP Participation Impacts Participant intent to apply for SNAP was captured for individuals reached through surveys administered at group presentations and forms completed during individual consultation sessions. Intent to apply for SNAP was not captured at booth events due to challenges with gathering sensitive information at large-scale events. Of the 340 people who reported intent, 90 (26.5%) indicated that they were planning to apply for SNAP based on messages learned from MIMB. The group survey gave participants an opportunity to share reasons for not applying. Nearly half (46.8%) reported that they already received benefits, 24.8% reported their income was too high, and 22% reported that they were not interested or did not need SNAP benefits. Participants who were planning to apply for SNAP were eligible to receive eligibility screenings and application completion assistance. Support was provided on-site in conjunction with MIMB events and through telephone contact via a toll-free line. During MIMB programs participants were provided with two methods to access telephonic support from MIMB State staff. Participants were provided referral cards bearing a MIMB toll-free number which gave them opportunities to initiate contact on their own. A second option is for participants to complete the contact information section of their group survey, booth evaluation, or individual consultation form to have a MIMB staff member contact them to provide assistance. Eligibility screenings were completed for 66 people (24 on-site and 42 via telephone) and applications were completed for 20 (3 on-site and 17 via

10 telephone). An additional 11 individuals who received screenings and planned to apply, preferred to fill out the SNAP application on their own rather than receive assistance. Limitations Given that booth presentations represented the majority of outreach contacts and that some participants elected not complete some sections of the surveys, it is important to note that the demographic data collected may not be representative of all individuals reached. Conclusions The MIMB project has been highly successful in increasing knowledge about and motivating sign up for SNAP. The curriculum is applicable for outreach efforts in other states especially if delivered through Cooperative Extension. References McClelland, J. W. and Bird, C. L. (in press). Best practices: Motivating Supplemental Nutrition Assistance Program (SNAP) application among older adults. The Forum For Family and Consumer Issues. Hanson, K. 2010. The Food Assistance National Input-Output Multiplier (FANIOM). Model and Stimulus Effects of SNAP. Economic Research Report No. (ERR-103), October 2010. USDA Economic Research Service, United States Department of Agriculture. Retrieved from http://www.ers.usda.gov/publications/err-economic-researchreport/err103.aspx#.uicui2txhrf Mathematica Policy Research. (2012). Reaching Those In Need: State Supplemental Nutrition Assistance Program Participation Rates in 2010. Retrieved from

11 http://www.fns.usda.gov/ora/menu/published/snap/files/participation/reachin g2010.pdf Mathematica Policy Research. (2012). Supplemental nutrition assistance program participation rates: Fiscal year 2010. Retrieved from http://www.fns.usda.gov/ora/menu/published/snap/files/participation/trends 2010.pdf Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. Applications to addictive behaviors. American Psychology, 47 (9), 1102-1114. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395. United States Department of Agriculture. (2012). Building a Healthy America: A Profile of the Supplemental Nutrition Assistance Program. Retrieved from http://www.fns.usda.gov/ora/menu/published/snap/files/other/buildinghealt hyamerica.pdf United States Department Of Agriculture. (2013, August 9). Retrieved from SNAP Monthly Data website: http://www.fns.usda.gov/pd/34snapmonthly.htm