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Correspondence: Address correspondence to Esme Fuller-Thomson, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Toronto, Ontario M5S 1A1, Canada. E-mail: esme.fuller.thomson{at}utoronto.ca
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Abstract |
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Key Words: Access • Andersen Behavioral Model • Food Stamp Programs • Poverty • Social Welfare Programs
Hunger in the United States is still a pressing social issue. One in eight households below the poverty line has at least one member who has experienced involuntary hunger because of insufficient funds to buy food (Nord, Andrews, & Carlson, 2004). Although access to the FSP is ostensibly offered to all eligible individuals living in poverty, research literature points to differential participation rates for diverse sectors of the American public. As a result, specific age cohorts and ethnic or racial groups require tailored outreach strategies to maximize their program participation. These strategies must be informed by solid research focused on each group's needs and patterns of utilization. In this article we study the characteristics of a particularly vulnerable subgroup: impoverished older Americans who are not receiving food stamps (The term impoverished refers to individuals who have incomes that are less than 100% of the poverty level.)
Numerous studies have reported that less than a third of eligible older Americans actually receive FSP benefits (Cunnyham, 2004; Haider, Jacknowitz, & Schoeni, 2003; Wilde & Dagata, 2002). These participation percentages are much lower than those for any other age group (Cunnyham, 2004; Rosso, 2001). Surprisingly, little research has focused on the characteristics of elderly persons who are eligible for the FSP but are not using the service. Even fewer studies have used multivariate models and theoretically informed analyses while attempting to describe this population.
Reasons for low program utilization rates among American seniors include the following: (a) barriers to information concerning eligibility, program benefits, and policies, which include confusion concerning changing eligibility standards; (b) enrollment impediments, which include difficulty accessing local welfare offices, misconceptions regarding application process complexity, and language issues; (c) concern about stigma, which may be more pronounced among older adults; and (d) perceptions concerning lack of need or inadequate benefits (Gabor, Williams, Bellamy, & Hardison, 2002; McConnell & Ponza, 1999; Parker, Jog, & Kennedy, 2005; U.S. General Accounting Office, 2000; Wilde & Dagata, 2002; Zedlewski & Rader, 2005).
As increasing numbers of Americans live to older ages, concern regarding their food security and the adequacy of their nutritional intake takes on added importance (Guthrie & Lin, 2002; Wellman & Kamp, 2004). The personal and social costs of elderly diet insufficiency include disease and disability exacerbation, depression, individual and caregiver strain, increased hospitalization, and earlier mortality (Food Security Institute, 2003; Lee & Frongillo, 2001). There is a need for timely research that focuses on the demographic characteristics of eligible elderly persons who do not use food stamps.
This research will generate a detailed profile of impoverished older Americans who, though eligible, are not accessing the FSP. A better understanding of the factors that distinguish participating and nonparticipating impoverished elderly Americans will address many of the gaps in our theoretical and practical understanding of elderly food stamp utilization and inform much needed program outreach efforts.
We use Andersen's (1995) behavioral model to predict the use of food stamps among older adults who are living in poverty. Andersen's framework has been one of the most influential models in the field of health care utilization over the past three decades (Calsyn & Winter, 2000; de Klerk, Huijsman, & McDonnell, 1997; Jang, Kim, & Chiriboga, 2005; Jheriot, Segal, & Cowser, 2003; Li, 2006). However, it has not commonly been used to assess utilization of social assistance programs. The model is a helpful theoretical framework for understanding the demographic, social, and situational factors influencing program-utilization patterns.
Andersen hypothesized that patterns of utilization are affected by predisposing, enabling, and need characteristics. In equitable services, need characteristics will be the strongest predictors of utilization. In inequitable services, enabling factors will provide the greatest explanatory power. We have modified these three groups of factors to address food stamp use. Predisposing characteristics include demographic characteristics such as age, gender, and race or ethnicity. Greater food stamp use has been associated with being female (Rosso & Faux, 2003), Hispanic (Faux & Rosso, 2003), African American (Faux & Rosso), and younger (Martin, Cook, Rogers, & Joseph, 2003). Characteristics that enable utilization of the FSP include skill in speaking English (Algert, Reibel, & Renvall, 2006), higher educational attainment (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993; Rank & Hirschl, 2005; Zedlewski & Rader, 2005), family composition, and use of other social assistance programs such as Supplemental Security Income (SSI) and public assistance (U.S. General Accounting Office, 2004; Zedlewski & Rader). Haider and colleagues (2003) reported that utilization rates were much higher among those individuals with children than among those without them. One possibility is that knowledge about and access to social assistance programs is increased through outreach programs in the schools, such as lunch programs or school social workers.
Need characteristics refer to health-related characteristics and financial status. In particular, we include the association between food stamp use and functional limitations, limitations in activities of daily living, and blindness or deafness. Rosso and Faux's (2003) analysis found that food stamp use was higher for individuals with disabilities than it was for those without them. Further, Rank and Hirschl (2005) found that duration of use was higher for those individuals with disabilities. Although all individuals studied were living below the poverty line, we included a variable in our analyses indicating household income as a percentage of the poverty line in order to identify those persons living in the most extreme poverty. The proposed analyses were to validate the Andersen behavioral model for predicting impoverished older adults' use of food stamps.
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Methods |
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Design and Procedure
We used SPSS 15.0 for Windows to conduct our analyses. In order to validate the Andersen Behavioral Model, we conducted both bivariate and multivariate tests. To assess whether groups (e.g., men and women) differed significantly in the percentage using food stamps, we conducted chi-square analyses for each of the predisposing, enabling, and need characteristics. A logistic regression analysis with food stamp use as the dependent variable was also necessary for two reasons. First, we were interested in whether each of the variables discussed here were independently associated with food stamp use, once the other variables were also included in the analysis. Second, Andersen's model is based on an investigation of groups of variables divided into predisposing, enabling, and need characteristics. An assessment of the change in the pseudo-R-squared value associated with each group of characteristics is an important way to ascertain whether service provision is based primarily on need or other factors.
For the logistic regression of food stamp use, we entered independent variables in three blocks: predisposing, enabling, and need characteristics. We assessed the independent contribution of each block of predictors, and we generated odds ratios (ORs) and 95% confidence intervals. Theory-driven hierarchical entry of each of the blocks of variables produced results that were more clearly interpretable (Phillips, Morrison, Andersen, & Aday, 1998).
Our analyses utilized a weighting variable designed by the U.S. Census Bureau. This weight variable represents the probability of selection, including noninterview adjustments and controlling for the 2000 Census housing units and population level. To avoid falsely increasing the likelihood that we would obtain a significant p value, we rescaled the weight variable to have a mean value of 1 for the subsample. We determined the receipt of food stamps by the participants' response to the following question: At any time in the past 12 months, did anyone in this household receive food stamps?
We based all variables on self-report, including ethnicity and race. We based household income on a summation of income for all household members from the following sources: (a) SSI; (b) public assistance or welfare payments from the state or local welfare office; (c) wages, salary, commissions, bonuses, or tips from all jobs; (d) self-employment income; (e) interest, dividends, net rental income, royalty income, or income from estates and trusts; (f) social security or railroad retirement; (g) retirement, survivor, or disability pensions; and (h) other sources of income received regularly such as veteran's payments, unemployment compensation, child support, or alimony. We dichotomized responses to the first two questions (yes or no) to determine if the household received SSI or welfare. The census calculated the household's family poverty level by using household composition and household income data. The sample was restricted to those below 100% of the poverty line. In 2003, the poverty line was $8,825 for an older adult living alone and $11,122 for an older couple (DeNavas-Walt, Proctor, & Mills, 2004). We then created a variable identifying four levels of poverty under the poverty line: (a) 0% to 24%, (b) 25% to 49%, (c) 50% to 74%, and (d) 75% to 99% of the poverty line.
Further, respondents were asked if they had either or both of the following long-lasting conditions: (a) blindness, deafness, or severe vision or hearing impairment; or (b) a condition that substantially limits physical activities such as walking, climbing stairs, reaching, lifting, or carrying. The former we labeled severe vision or hearing difficulty and the latter we defined as functional limitations. Respondents were also asked if they had a physical, mental, or emotional condition lasting 6 months or more that made it difficult to do any of the following: (a) learning, remembering, or concentrating; (b) dressing, bathing, or getting around inside the home; (c) going outside the home alone to shop or visit a doctor's office; and (d) working at a job or business. For the purposes of this study, we defined these as difficulty remembering, limitations in activities of daily living, difficulty going out, and difficulty working, respectively.
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The logistic regression (see Table 2) presents the independent contribution of each of the characteristics, controlling for the other variables in the analysis. All four of the predisposing characteristics were significant. Women, Hispanics, and African Americans had higher odds of food stamp use. In comparison with those individuals aged 85 years and older, those aged 65 to 74 had almost three times the odds of using food stamps.
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The change in the pseudo-R-square value indicated that need characteristics explained a total of 6.6% of the model variance. In comparison with those individuals living below 25% of the poverty line, persons in each successive quintile had higher odds of using food stamps (OR = 1.50, 2.21, and 2.79, respectively). In comparison with those persons who owned their own home and had paid off their mortgage, the odds of food stamp use was significantly higher among owners with a mortgage (OR = 1.25), those who lived with others without paying rent (OR = 1.56), and highest among those who rented their accommodation (OR = 2.64). Those with vision or hearing difficulties, functional limitations, or disabilities that impacted their ability to work had elevated odds of using food stamps. Several of the need characteristics that had reached the level of significance in the bivariate analyses were no longer significant in the multivariate analyses (i.e., limitations in activities of daily living, difficulties in going out, and difficulties remembering).
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Discussion |
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Despite these limitations, the analyses do provide some helpful insights into the characteristics of impoverished older Americans who do not use food stamps. Using 2003 data, we found an overall prevalence rate of 19.2%. This percentage is considerably lower than the 26.9% (Cunnyham, 2004) and 30% (Wilde & Dagata, 2002) previously identified in studies of those individuals aged 60 and older. In contrast, our sample included only those aged 65 and older. We found that participation rates were much higher among the younger cohorts, and thus the different age minimum may partially explain these disparities. Furthermore, as we already discussed, we may have included in our sample some older adults who were ineligible for food stamps as a result of wealth, which we could not assess.
Predisposing Characteristics
Our results support the findings of the previous literature indicating that food stamp rates are higher among women, African Americans, and Hispanics (Faux & Rosso, 2003; Rosso & Faux, 2003). However, even in these groups, utilization rates are still abysmal. At least two thirds of those persons eligible in each of these populations are not receiving food stamps.
This study's finding that the younger cohort (age 65–74) had almost three times the odds of food stamp use as compared with the oldest respondents (age 85 and older) is provocative. Rogers-Dillon (1995) suggests that welfare stigma is produced through an interaction between an individual's life history, situation, and social audience. An earlier incarnation of the FSP was inaugurated in 1939 to provide support to the neediest among the poor. One explanation for the reticence of the oldest respondents is the possibility of greater concern over "welfare stigma" among those who lived through the Depression era during their adolescence and young adulthood. In addition, although food stamps should not be synonymous with welfare, it is important to note that many states require that applicants visit the same location in order to enroll in either assistance program. Florida, Kansas, New Jersey, and West Virginia are among a handful of states that permit online applications.
Furthermore, the historic practice in which individuals physically hand over the food stamps to their local store when they pay for their groceries may be associated with public shame. Most states are now using electronic benefit transfer cards. Similar to debit cards, electronic benefit transfer cards were ostensibly introduced to counteract fraud but may also serve to minimize stigma (Food Stamp Program: Frequently Asked Questions, n.d.). This being said, the imposition of new technology may still serve to alienate the oldest eligible Americans. With nine out of ten of the oldest cohort not receiving food stamps, it is clear that focused outreach and public education to destigmatize the FSP are necessary.
Enabling Characteristics
Several of our findings on enabling characteristics were in opposition to our hypotheses and the previous research on the topic. For instance, although we were not able to assess differential access rates among various linguistic groups, we anticipated that, because they would have more difficulties learning about and accessing the service, those persons with low English proficiency would have lower rates of FSP participation. Although our expectations were in keeping with the research by Algert and colleagues (2006), this did not prove to be the case.
Perhaps our finding of higher use among nonanglophones may be due to the fact that a lack of English skills is highly correlated with duration of poverty (Urban Institute, 2002, 2006). Greater duration of poverty, in turn, is associated with a higher likelihood of accessing social services. Another potential explanation is that the FSP has made a substantial effort to provide Spanish material and bilingual staff. The greater rates of utilization among non-English-speaking older adults may reflect the success of this outreach. This might also explain our surprising finding that, among impoverished Americans, those who were citizens through naturalization rather than through birth were more likely to use food stamps.
We had anticipated that education would facilitate access to services, as is the case in medical care (U.S. Department of Health and Human Services, 1998). However, our findings indicate that there is a higher likelihood of food stamp utilization among the poorly educated. Typically, lower levels of educational attainment are associated with lower wages and less job security, and thus a greater need over the years to use food stamps. Furthermore, well-educated older adults are more likely to have accrued wealth and thus be ineligible for services. As we already mentioned, our inability to determine wealth may have resulted in the improper inclusion of some individuals in our subsample.
Three of our enabling characteristics did support our original hypotheses: Children present in the home, receipt of welfare, and receipt of SSI were each associated with higher food stamp utilization. The pseudo-R-squared statistics indicate that almost 10% of the variability in the logistic regression was explained by the latter two variables. Although it appears that many welfare workers are connecting clients to the FSP, there are still more than 40% of welfare recipients who are not getting food stamps. Many states may benefit from adopting a strategy such as the one used in Maine.
Maine has provided leadership in the linking of social welfare benefits through an integrated computer system. When an individual applies for one benefit program (e.g., Medicaid or welfare), eligibility for the FSP is concurrently assessed. Eligible individuals are then immediately invited to apply for food stamps and other appropriate programs (Wallack, 2006). This outreach project contributed to a 49% increase in food stamp participation between 2002 and 2005 (Acheson, 2006). Initiatives such as this hold great promise for improving access to food stamps for impoverished older Americans.
Need Characteristics
Andersen's framework proposes that those individuals with greater need are more likely to use services. In the bivariate analyses, all six types of disabilities were associated with greater utilization of food stamps. This was in keeping with earlier research (Rosso & Faux, 2003). Those persons with disabilities may have both a greater need for food stamps and a longer duration of need (Rank & Hirschl, 2005). However, in the logistic regression analyses, only three of the six variables remained statistically significant.
It is not surprising that we found that those individuals who owned their accommodation mortgage free had much lower food stamp utilization rates. Low-income older adults who are renters and, to a lesser extent, those who continue to have mortgage payments devote a higher proportion of their income to housing and related costs. This results in less disposable income for purchasing food and other necessities, thus contributing to a greater need for social service support such as the FSP. Although subsidized housing is one way of increasing the disposable incomes of older renters living in poverty, applicants often face overly long waitlists. In one tenth of the Section 202 sites, waitlists have been closed because demand has vastly outstripped supply (Kochera, 2006).
In contrast to our expectations, we found that those who were in the poorest quartile of the poverty index (0% to 24% of the poverty line) had the lowest levels of food stamp utilization. In 2003, this level of poverty indicated an annual income of $2,206 or less for an older adult living alone and $2,781 or less for an older couple. Only 1 in 15 older adults living in this level of extreme poverty was receiving food stamps. We hypothesize two reasons for this. First, if people in this economic situation applied for food stamps, it is probable that they would also be referred to welfare or SSI for assistance. Once welfare or SSI was received, their income would be considerably above the 25% of the poverty-line cutoff we have specified here. Second, the strongest association we found in our analyses was between welfare, SSI, and food stamp use. We anticipate that much of this association is related to the situation in which welfare recipients are referred to or screened for the FSP program by their welfare or SSI worker. It is probable that those in the lowest poverty quartile are not receiving any government subsidies such as welfare, a program designed to move families well above 25% of the poverty line. Thus, those in this lowest income category are probably not in contact with welfare workers who could inform them about the FSP. Although only 12% of older adults living under the poverty line are in this lowest income category, it is imperative that future outreach targets this particularly needy and underserved group.
Although the pseudo-R-square value indicates that Andersen's framework explained a substantial proportion (i.e., 28%) of the variability in food stamp utilization in older adults living below the poverty line, the model definitely requires further refining. The fact that the direction of the association between several key determinants and utilization was the reverse of what we had anticipated indicates the pressing need for further research. Qualitative research might help researchers understand how impoverished older adults learn about their eligibility for the FSP and what factors motivate or dissuade them from program participation.
A comparison of pseudo-R-square values suggest that enabling characteristics explained twice the variability associated with either predisposing or need characteristics. This is indicative of an inequitable pattern of service utilization. In an equitable system, need should be the predominant factor associated with utilization. Our findings may have been influenced by the narrow subsample we selected: All older adults in our sample were living below the poverty line and therefore, by definition, had need. However, additional need-related factors such as degree of poverty within this subsample, housing tenure, and disability levels were associated with a change in the pseudo-R-square value of only 7%.
The gap in service delivery to older adults living in poverty is stark. Even among those persons receiving welfare or SSI, fewer than 60% were concurrently receiving food stamps. In no other examined subgroup did we find more than 40% accessing the program. Nine out of ten impoverished Americans aged 85 and older were not receiving food stamps.
Clearly targeted outreach to this population is essential. It would be beneficial for the FSP to set older adult participation rate targets for 2010 and 2020 in order to keep this population's needs in the forefront of program planning. Concomitantly, the FSP will have to annually assess the participation of older adults.
Several promising strategies have been proposed to improve food stamp utilization rates. Community education could address erroneous perceptions regarding low program benefits. Creating mobile and satellite food stamp offices in lower income neighborhoods would improve access, as would offering online application forms in all states (Martin et al., 2003). Furthermore, having these sites be distinct from welfare offices may decrease the perceived stigma attached to food stamp use.
Although there is a general online prescreen tool available (U.S. Department of Agriculture, Food and Nutrition Service, n.d.b), the application process itself could be improved. For example, in the state of Maine, employees determine eligibility before individuals begin the social service application process (Wallack, 2006). Reducing the length of the application form would also facilitate greater utilization (Martin et al., 2003). Innovative outreach programs that collaborate with community partners, such as faith-based organizations, health organizations, and school programming, could positively influence participation rates (Food Research and Action Center, 2006). These strategies could easily be adapted to focus specifically on older adults. More extensive multilingual service provision, and more assistance for the illiterate and those with visual or hearing impairments could also be of value. Home visits by FSP workers to the functionally impaired could also improve access.
Further education of SSI, welfare, public housing, and senior community center workers on the importance of referral to the FSP could also improve access for those older adults who are using other services. Mailed brochures on the FSP, eligibility criteria, and local contact information could be sent to all older adults receiving SSI, welfare, public housing, and Medicaid, as well as to those whose Social Security payments are below the poverty line. With the vast majority of impoverished older adults not receiving food stamps, strategies such as these are extremely important to rectify this situation among the most vulnerable group of older Americans.
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1 Faculty of Social Work, University of Toronto, Canada.
Decision Editor: William J. McAuley, PhD
Received for publication March 14, 2007. Accepted for publication July 5, 2007.
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