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Food insecurity in Greater Vancouver : a mixed methods exploratory study with food bank members Holmes, Eleanor 2017

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FOOD INSECURITY IN GREATER VANCOUVER: A MIXED METHODS EXPLORATORY STUDY WITH FOOD BANK MEMBERS    by Eleanor Holmes, RD B.Sc., The University of British Columbia, 2009   A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Human Nutrition)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   January 2017     © Eleanor Holmes, 2017   ii Abstract  Background: Household food insecurity (HFI), defined as limited access to adequate, safe, and nutritious food, was estimated to affect 13% of Canadian households in 2012. In Canada one of the primary efforts to support food insecure households are food banks. Although food bank use is on the rise in Canada, few studies have described the diverse experiences of individuals who use them. This study examined characteristics and experiences of food bank users, including socio-demographic characteristics, severity of HFI, patterns of food bank use, and current challenges and preferences for services.   Methods: This mixed-methods study involved interviewer-administered surveys (n=77) and 5 focus groups (n=27) with food bank members from Vancouver, BC. Surveys assessed socio-demographic and health characteristics, food bank use, and satisfaction with services. Focus groups examined experiences, challenges, and recommendations for improving services. Survey analyses included descriptive statistics and Fisher’s exact tests to explore associations with severe HFI. Thematic analysis was used for focus group data.   Results: Inadequate income emerged as the most prominent factor influencing food bank use. Survey respondents reported severe food insecurity (66%), health challenges (77%), reliance on social assistance (84%), and long-term (>5 years) food bank use (54%). Monthly income level (<$1800) and rental costs (>$500) were significantly associated with severe HFI (p<0.05), however, frequency and duration of food bank use were not. Although survey and focus group participants indicated that food banks did not provide enough food to meet their needs, participants reported positive experiences at the food bank and most anticipated needing these services in future. Focus group discussions highlighted improving food provision quality and quantity, and creating more safe and supportive environments. Linking with health supports and participating in advocacy towards poverty reduction were also suggested.   Significance: Food banks are an entrenched, long-term strategy for households driven by inadequate financial resources to access food. While gratitude for food bank services was apparent, this study supports growing evidence that food banks are an insufficient response to food insecurity. Participant envisioned ways that food bank organisations can adjust to better support their users included updates to current services that incorporate health, wellness, and advocacy.       iii Preface This thesis is the original work by the author, Eleanor Holmes. This thesis is a part of a larger community based research partnership. The author was not a contributor to the initial identification of this research partnership, but the research questions and design of the study outlined in this thesis came through collaboration between the author, the Greater Vancouver Food Bank management team, and research study members: Dr. Jennifer Black (Graduate supervisor), Dr. Scott Lear (Graduate Committee Member), Dr. Susan Barr (Graduate Committee Member), Dr. Hannah Wittman, Amber Heckelman (Graduate student), Aart Schuurman Hess, Darlene Seto, Trish Kelly, and James Ash.  The author contributed in the development of the survey including question selection, survey piloting, and question revision. The author was the primary person responsible for engaging with volunteers at each of the sites where surveys and focus groups were held, and developing appropriate protocols for recruitment and community engagement strategies. The author additionally led the application process to obtain ethical approval through the UBC Behavioural Research Ethics Board (H15-001180). Collaboration and integration of feedback from the Greater Vancouver Food Bank management team, volunteer team, and research team members was done for each of these components throughout the research process.   The author was responsible for the management and training of 3 research assistants, including 1 peer research assistant. For the survey component, the author led approximately 20% of the interviewer-administered surveys. Amber Heckelman (Graduate student) led all focus group sessions and research assistants transcribed the recordings of these discussions. The author independently analysed both survey and focus group data and wrote the thesis, with guidance and feedback from Dr. Jennifer Black, Dr. Scott Lear, Dr. Hannah Wittman, Dr. Susan Barr and Dr. Nathanael Lauster.       iv Table of Contents  Abstract .......................................................................................................................................... ii	  Preface ........................................................................................................................................... iii	  Table of Contents ......................................................................................................................... iv	  List of Tables .............................................................................................................................. viii	  List of Figures ............................................................................................................................... ix	  List of Abbreviations ..................................................................................................................... x	  Acknowledgements ...................................................................................................................... xi	  Dedication .................................................................................................................................... xii	  Chapter 1: Introduction ................................................................................................................1	  1.1	   Background and study rationale ......................................................................................... 1	  1.2	   Study purpose..................................................................................................................... 2	  Chapter 2: Literature Review .......................................................................................................4	  2.1	   Household food insecurity ................................................................................................. 4	  2.1.1	   Definition .................................................................................................................... 4	  2.1.2	   Classification and measurement ................................................................................. 5	  2.2	   Canadian response to household food insecurity ............................................................... 6	  2.2.1	   Federal and provincial income support ....................................................................... 7	  2.2.2	   Municipal food-based approaches .............................................................................. 8	  2.3	   Food banks ......................................................................................................................... 9	  2.3.1	   Food bank member characteristics ............................................................................ 10	  2.3.1.1	   Demographic and socioeconomic status ............................................................ 10	  2.3.1.2	   Health status ....................................................................................................... 12	  2.3.1.3	   Household food insecurity status ....................................................................... 13	  2.3.1.4	   Patterns of food bank use ................................................................................... 15	  2.3.2	   Evaluating the food bank response to household food insecurity ............................. 16	  2.3.3	   Experiences and challenges with food bank services ............................................... 17	  2.3.3.1	   Food quantity, quality and preferences .............................................................. 17	  2.3.3.2	   Operational barriers ........................................................................................... 19	  2.4	   Food bank transformations .............................................................................................. 20	    v 2.4.1	   Community Food Security Continuum framework .................................................. 20	  2.4.2	   Vancouver context .................................................................................................... 22	  2.4.3	   Community based participatory research .................................................................. 23	  2.4.4	   Mixed methods research ........................................................................................... 23	  2.5	   Objectives ........................................................................................................................ 24	  2.5.1	   Study 1 ...................................................................................................................... 25	  2.5.2	   Study 2 ...................................................................................................................... 25	  2.6	   Summary .......................................................................................................................... 26	  Chapter 3: Food insecurity in Greater Vancouver: exploratory findings from a community consultation with food bank members .......................................................................................28	  3.1	   Introduction ...................................................................................................................... 28	  3.2	   Methods............................................................................................................................ 30	  3.2.1	   Participant recruitment .............................................................................................. 30	  3.2.2	   Survey ....................................................................................................................... 31	  3.2.3	   Food bank organizational records ............................................................................. 34	  3.2.4	   Data collection .......................................................................................................... 35	  3.2.5	   Analysis..................................................................................................................... 36	  3.3	   Results .............................................................................................................................. 37	  3.3.1	   Sample characteristics ............................................................................................... 37	  3.3.2	   Food bank use ........................................................................................................... 39	  3.3.3	   Household food insecurity and hunger ..................................................................... 40	  3.3.4	   Associations between household food insecurity and sample characteristics .......... 40	  3.3.5	   Food bank organizational records ............................................................................. 41	  3.4	   Discussion ........................................................................................................................ 43	  3.4.1	   Demographic characteristics ..................................................................................... 43	  3.4.2	   Food bank use ........................................................................................................... 46	  3.4.3	   Resources used to obtain food .................................................................................. 46	  3.4.4	   Household food insecurity ........................................................................................ 47	  3.4.5	   Strengths and limitations ........................................................................................... 48	  3.5	   Conclusions ...................................................................................................................... 49	    vi Chapter 4: “Nothing is going to change three months from now.” Insights from a mixed methods characterization of food bank use in Greater Vancouver ........................................50	  4.1	   Introduction ...................................................................................................................... 50	  4.2	   Methods............................................................................................................................ 52	  4.2.1	   Participant recruitment .............................................................................................. 54	  4.2.2	   Data collection methods ............................................................................................ 55	  4.2.2.1	   Qualitative .......................................................................................................... 55	  4.2.2.2	   Quantitative ........................................................................................................ 56	  4.3	   Analysis............................................................................................................................ 58	  4.3.1	   Qualitative data analysis ........................................................................................... 58	  4.3.2	   Quantitative data analysis ......................................................................................... 58	  4.3.3	   Mixed methods analysis ............................................................................................ 59	  4.4	   Results .............................................................................................................................. 59	  4.4.1	   Participant characteristics ......................................................................................... 59	  4.4.2	   Qualitative results ..................................................................................................... 61	  4.4.3	   Mixed method results ................................................................................................ 63	  4.4.3.1	   Food banks as a long-term resource ................................................................... 65	  4.4.3.2	   Experiences and visions for the future of the food bank system ....................... 66	  4.5	   Discussion ........................................................................................................................ 71	  4.5.1	   Food banks as a long-term resource .......................................................................... 71	  4.5.2	   Experiences and visions for the future of the food bank system .............................. 72	  4.5.3	   Strengths and limitations ........................................................................................... 77	  4.6	   Conclusion ....................................................................................................................... 78	  Chapter 5: Conclusion .................................................................................................................79	  5.1	   Contributions and significance ........................................................................................ 79	  5.2	   Strengths and limitations .................................................................................................. 84	  5.3	   Application of findings .................................................................................................... 87	  5.4	   Future research direction .................................................................................................. 87	  References .....................................................................................................................................89	  Appendices ..................................................................................................................................101	  Appendix A Food bank site profiles ....................................................................................... 101	    vii Appendix B Survey - Food insecurity in Greater Vancouver: community consultation with food bank members ................................................................................................................. 102	  Appendix C Policy and protocol manual ................................................................................ 127	  C.1	   Policy 010: Study participant recruitment ................................................................. 127	  C.2	   Policy 020: Study participant consent ....................................................................... 129	  C.3	   Policy 030: Survey administration ............................................................................ 131	  C.4	   Policy 040: Physical safety for field research ........................................................... 133	  C.5	   Policy 050: Emotional and psychological distress .................................................... 135	  Appendix D Survey results ..................................................................................................... 137	  Appendix E Sensitivity analysis with imputations for missing MMS use data ...................... 145	  E.1	   Length and frequency of food bank use .................................................................... 145	  E.2	   Associations between length and frequency of use and severe HFI ......................... 145	  Appendix F Supplementary tables .......................................................................................... 146	  F.1	   Associations between alternative categorization of income and housing costs and severe HFI ........................................................................................................................... 146	  F.2	   Association between income and severe HFI, controlled by housing costs .............. 146	  F.3	   Associations between hunger decrease and adequacy of food bank provisions and severe HFI ........................................................................................................................... 147	  F.4	   Associations between length and frequency of food bank use and hunger decrease 147	  F.5	   Associations between length and frequency of use and adequacy of food bank provisions ............................................................................................................................ 148	  Appendix G Comparison of food bank member sample and population characteristics ........ 149	     viii List of Tables  Table 3-1 Household food insecurity categorization scoring ....................................................... 33	  Table 3-2 Food bank member sample characteristics ................................................................... 38	  Table 3-3 Length and frequency of food bank use ....................................................................... 39	  Table 3-4 Experiences with household food insecurity and hunger ............................................. 40	  Table 3-5 Associations between severe HFI and food bank member characteristics ................... 42	  Table 4-1 Focus group and survey questions ................................................................................ 57	  Table 4-2 Food bank member sample characteristics, survey and focus groups .......................... 60	  Table 4-3 Thematic coding and prevalence of themes for projected food bank use .................... 61	  Table 4-4 Thematic coding and prevalence of themes for experiences and visions for the future of the food bank system ................................................................................................................ 61	  Table 4-5 Side-by-side analysis of qualitative and quantitative data ........................................... 63	  Table 5-1 Recommendations to improve food banks services ..................................................... 83	     ix List of Figures  Figure 2-1 Current approaches to address household food insecurity in Canada ........................... 7	  Figure 2-2 Community Food Security Continuum framework, adapted to address HFI .............. 22	  Figure 4-1 Concurrent convergent mixed methods design ........................................................... 54	     x List of Abbreviations  BC  British Columbia CCHS  Canadian Community Health Survey CBPR  Community based participatory research GVFB  Greater Vancouver Food Bank GVRD  Greater Vancouver Regional District HFI  Household food insecurity HFSSM Household food security survey module PRA  Peer research assistant MMS  Member management system SFU  Simon Fraser University UBC  University of British Columbia UK  United Kingdom US  United States        xi Acknowledgements This work could not have been completed without the vision and assistance of so many individuals. I feel incredibly grateful and honoured to have been surrounded by such a passionate and vibrant community throughout the course of this work. First and foremost, I extend my deepest thanks for my supervisor Dr. Jennifer Black whose support and encouraging guidance helped me to traverse the many hurdles throughout the research process. Your optimism, trust, flexibility, and funding were incredibly appreciated over the past two years.   I offer endless thanks to the hardworking, kind, and talented team at the Greater Vancouver Food Bank – Aart, Darlene, Trish, James, Diane, Craig, Frank and others. Your invaluable assistance throughout this work helped us to ensure that this research was relevant, and that our process was safe and respectful for everyone involved. To all food bank members who took the time to speak with us or participate in our study, and to all the volunteers and members who make the food bank a community– thank you for sharing your stories and your spaces with us.    I greatly benefited from taking a graduate level course with Dr. Susan Barr, and from having her on my advisory committee. Your rigour and dedication to the field of nutrition is inspiring. Thank you to Dr. Scott Lear for your insightful comments and perspectives throughout the entire process. I was lucky to benefit from your expertise. To my PHUN group mates, thank you for being available to throw ideas and questions at, and for providing your honest opinions. To the other members of the research team - Joanna, Amber, Adeleke, Vera, Myra, and Loulou – I could not have done this without you. Thank you for being the eyes, ears, hands, and hearts out in the field. A special thank you to Vera, our Peer Research Assistance extraordinaire. You were a source of strength for all of us, and our society is made more beautiful with individuals like you in it. Thank you.   To my parents for their unwavering support in all that I decide to do. Knowing I had a safety net gave me the courage to follow my interests. My greatest wish is that Canada continues to work proactively towards building the needed systems to ensure that all citizens of this country can say the same. Finally, to my partner Ilia: What a whirlwind two years this has been. Thank you for keeping me smiling through it all. Dedication   xii Dedication For Dynamite.  1 Chapter 1: Introduction 1.1 Background and study rationale  Household food insecurity (HFI), defined as limited or insecure financial access to adequate foods (1), is a rising concern in Canada. In 2012 it was estimated that 1.7 million Canadian households – or 13% - were living with some level of food insecurity, reflecting an increase of 300,000 households since 2007 (1). Poverty and socio-economic disadvantage are closely tied to HFI in Canada, as HFI has been found to be associated with low income and subsequent insufficient purchasing power to obtain food (1–7). Cross sectional survey data indicate that HFI is associated with decreased intake of nutrient dense foods and a higher prevalence of inadequate nutritional intake (8,9). HFI has additionally been associated with the prevalence of mental health issues related to anxiety, depression, and stress (6,7,10,11) as well as poor self-rated health, chronic disease, poor disease outcomes, and higher health care needs (6,7,11–14). These significant social and health disparities pose a major yet preventable public health issue, and avenues to assist in reducing experiences of HFI should be explored.  In Canada, one of the primary efforts employed to support food insecure households are food banks (15,16). Food banks generally function as food redistribution centres, providing the capacity to collect, store, and sort donated food items. They collect food from the community via reclamation from large food producers and retailers, as well as through donations from community food drives and charitable giving (17,18). These food items are then stored, sorted, and shipped off to local food programs and food bank distribution sites where they can be given to individuals in need. Food banking programs were initially opened in the 1980’s in Canada to provide emergency food supplies to those affected by the 1981 – 1985 economic recession (19). However, since that time the number of food banks in Canada has continued to rise (15,17) and in 2015 over 850,000 individuals were assisted by a food bank in Canada in a single month, representing a 26% increase since the economic crisis of 2008 (20). Furthermore, research from the United States (US) and Canada suggest that food banks are not being used solely as an ‘emergency’ response, and are being used by some members1 over the long term (21–25).                                                 1 Individuals who use food banks are referred to as clients, users, families, and participants throughout the literature. To align with the language of our local food bank community partner, the term ‘members’ will be utilised throughout this thesis to designate all food bank clients.    2 Although initially believed to be a temporary solution to emergency hunger, these facts describe the entrenchment of food banks within the Canadian food system (15), warranting closer inspection to understand who are using food banks in Canada and how they are being used.  Food banks have gained wide public and corporate support (15), and by improving immediate food access food banks have been reported to be perceived by community members, including those working with food insecure populations, as an appropriate avenue to decrease hunger in the short term (26,27). However, it has been found that reliance on donations and operational constraints limit food banks’ control over the quality and quantity of the foods they provide, resulting in limitations to effectively meet the needs of those who access them (15,17,28). Furthermore, critiques of food banks include concerns that they do not address the factors that underlie food insecurity, namely poverty and lack of adequate financial access to food (15,29), and evidence that they are able to improve food security outcomes is lacking (16).  Food banks are interested in working towards improving their capacity to better support their members, and some food bank organizations have begun making updates to their services (30,31). However, studies that assess these changes are sparse. As reflected through conversations with leaders of a local Vancouver food bank organization, as they begin to initiate changes to their service model they want to ensure updates are evidence based and reflect and honour their members’ dignity, preferences, and input (personal communication, Aart Schuurman Hess, January 2015). A community based participatory research study conducted using a mixed methods approach was devised in order to meet the food bank’s organizational knowledge needs, fill in evidence gaps regarding members’ experiences with food bank use as a buffer to food insecurity, and provide space for members to reveal how they envision the food bank updating their services to better meet their needs.  1.2 Study purpose This mixed methods study consisted of a quantitative cross sectional survey and facilitated focus group discussions with a sample of Vancouver food bank members. This thesis provides insight regarding the socio-demographic characteristics, HFI status, and food bank use patterns of food bank members, and an enhanced understanding of food bank members’ perspectives and experiences using food banks in Vancouver. The overall aim of this thesis is to   3 contribute to the knowledge base required to inform future interventions aimed at alleviating HFI in Canada. The work here will additionally serve as a baseline for a local food bank organization to develop future service changes and longitudinal evaluation of their programs.     4 Chapter 2: Literature Review  The purpose of this literature review is to summarize existing research that has examined HFI in Canada. The review will begin by defining and outlining the issue of HFI and its measurement in Canada. This will be followed by a review of the current approaches being used to address HFI in Canada, with a focus on food banks. I will examine literature surrounding the food bank response including socio-demographic characteristics of food bank members, and how food bank use is currently understood to relate to the severity of HFI. Existing literature looking at food bank members’ experiences and critiques of the charitable food bank system will be summarized. Finally, I will discuss the use of community based participatory research frameworks, and the absence of literature that has used a mixed methods approach to assess experiences of food bank members.    2.1 Household food insecurity 2.1.1 Definition  Food security describes a situation where “all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food which meets their dietary needs and food preferences for an active and healthy lifestyle”(32). In the western world where food is abundant, lack of food security at the household level has been found to be less related to physical and social factors that limit food access and is primarily associated with insufficient economic access (6,33). Consequently, HFI - which indicates limited access to sufficient, safe, and nutritious food at the household level - is understood in Canada to be financially determined (2,4–7).  Notably, some definitions of HFI include the inability to acquire food in “socially acceptable ways” (34). Currently from the literature it remains in contention if charitable food program use can be seen as ‘socially acceptable’. Although Hamelin et al noted in 2002 that food bank use appeared to have become an accepted part of life for many who use them (35), and Starkey et al found that food bank clients viewed the assistance as a necessary community service (23), use of these programs have largely been viewed as socially undesirable. This is due to reports that obtaining food through these programs is degrading, deviates from social norms, and fosters social exclusion and alienation (28,35,36). Given that all participants in this study   5 will have accessed charitable food, which alone provides evidence of food need, it could be argued that all participants are in fact food insecure. However, as we will be measuring HFI using a standardized tool that focuses on financial access, and does not specifically measure social acceptability of food access, for the purposes of this thesis the definition of HFI has not included the domain of social acceptability.    2.1.2 Classification and measurement  HFI in the western world has been determined through qualitative analysis to be experienced in a graded manner; commencing with experiences related to anxiety regarding access to food and whether or not food will last, followed by compromises in food quality, and in the most severe cases resulting in decreases in quantity anywhere from restricting portion sizes to going entire days without eating (35–38). This understanding has led to the development of survey tools that can effectively categorize these differing levels of experience. This includes the Household Food Security Survey Module (HFSSM) used in national Canadian and US surveys to measure household food insecurity (39,40). This tool poses a series of ten questions that elucidate adult experiences with household food supply, with eight additional questions related to children’s experiences for respondents with children less than eighteen years of age in the home. Reflective of the number of affirmative responses provided, household food insecurity is categorized across a spectrum to describe the severity of financially limited food access. Statistics Canada currently uses the following classifications for food insecurity (1,39):   Food secure    - no or minimal concerns with food access  Moderate food insecurity  - compromises in the quantity or quality of food intake Severe food insecurity  - episodes of hunger and skipped meals   However, researchers are increasingly using even minimal concerns with food access as an indication of food insecurity, as all questions in the module suggest uncertain food access (1,28). It was determined in a US study that households who answered affirmatively to one or two questions had lower incomes, education levels, employment status, and spent less money on food than those who did not answer affirmatively to any questions (41). A research team leading the monitoring of food insecurity in Canada presents food security using an alternate   6 classification range to recognize this group – marginal food insecurity - indicated by a single affirmative response to the HFSSM module (1). Recognizing that psychosocial aspects of food insecurity and worry about running out of food could result in food bank use, or remain ongoing despite food bank use, this thesis utilises their classification of food insecurity, as follows:  Food secure    - no concerns with food access Marginal food insecurity  - a single report of inadequate food access or anxiety related to inadequate food access Moderate food insecurity  - compromises in the quantity or quality of food intake  Severe food insecurity  - episodes of hunger and skipped meals   Notably, the standardized HFSSM questions were developed to determine a household’s income-related access to food. While this relates to the monetary underpinnings determined to be the primary cause of HFI in Canada (1,4,6,7), and assists to prevent the misclassification of individuals who actively restrict their intake for other reasons such as dietary restrictions or weight loss (39), it does miss out on other non-financial methods of food access. For instance, the impact that alternative methods of food access have on hunger - such as charitable food assistance or obtaining food from friends or family - are not directly measured on this scale. The HFSSM remains the standardized and validated tool used in Canada, and therefore the best measure to categorize severity of HFI and compare to larger national surveys. However, alternate questions should additionally be posed when surveying this population group to more effectively determine the impact of food bank program use on members’ hunger.   2.2  Canadian response to household food insecurity According to the HFI action framework described by Collins et al (16), in Canada there are currently two levels of approach towards addressing household food insecurity: federal and provincial income based support, and municipal and community level food based programming (Figure 2-1).      7  Figure 2-1 Current approaches to address household food insecurity in Canada                    (Adapted from Collins et al (16))  2.2.1 Federal and provincial income support As a liberal-welfare state, Canada administers federal and provincial income support programs to provide increased access to income through social assistance (i.e. welfare and disability support), employment insurance, pensions, child tax benefits, and rental assistance (42,43). These programs are thought to assist in attenuating HFI by increasing financial resources available to spend on food. However, research conducted in Canada has repeatedly shown that households reliant on income support programs, namely social assistance through welfare and disability support, have increased likelihood of experiencing food insecurity (4,6,7,28,39). In 2001, Canadian Community Health Survey (CCHS) data revealed that those receiving social assistance had three times higher odds of experiencing HFI than those not receiving this assistance (6). More recently, a report examining CCHS data from 2012 found that 70% of Canadian households who indicate reliance on social assistance report experiencing food insecurity (1). In British Columbia (BC), the prevalence of households on social assistance who were classified as food insecure was even higher than the national level, at 76% (1). Biennial reports published since 2005, outlining the cost of food in BC, have also consistently reported that current social assistance rates do not reflect the finances needed to ensure sufficient access to adequate, safe, and nutritious food after other costs of living are taken into account (44–46).    8 2.2.2 Municipal food-based approaches Given the inadequacy of the federal and provincial income support model, local food-based programs have been taking on a greater role to address food insecurity, as evidenced by the increasing number of these services over the past thirty years (15,17,19,47). These programs focus on food-based initiatives to decrease HFI by improving food access and are delivered via three approaches: charitable giving, household improvement and support programming, and community food systems work (16).  The charitable model historically has been run through faith groups and community organizations, aiming to provide grocery items or meals at no cost to those who choose to access their programs. These programs, namely food banks and free meal programs, focus on immediate food need and are largely reliant on input from volunteers and donations from the public and the food industry (19).  The household improvements and supports model, tied with ideas from health promotion, has aimed to be more educational and participatory in nature, where goals focus on empowerment and self-efficacy by improving food literacy and skills – including food production, healthy food selection, nutrition knowledge, and food preparation (19). These programs function as community kitchens, nutrition education programs, and community gardens, where the additional benefits of social cohesion, dignified food access, and community building can take place (16,48). Due to the skill building nature of these activities - and understanding that these programs can assist communities to reach specific social, environmental, and health targets - some programs may fall under the umbrella for government or health authority funding and support (49,50). However, in many cases the community organizations that run these programs are not directly funded by governments or health authorities, and therefore still need to fundraise, obtain grants, and/or rely on charitable donations and volunteers in order to facilitate them (51,52).  The community food systems model represents initiatives that are often created through partnerships among municipal governments, activists, and local service and food providers (16). The aims of this work look at the broader food system, and encourage improved connections and policies to create a “sustainable food system that maximizes community self-reliance and social justice”(53). Although this model does not primarily focus on HFI, the discourse and municipal   9 policy changes that result from these initiatives will be vital for an organised and cooperative strategy to combat HFI (16,54).  For the purpose of this thesis, the literature review and research will be focused on the charitable food bank response. However, discussions regarding the role that food banks have to play in other levels of the municipal-level response will be included.  2.3 Food banks  While food insecurity and ad-hoc charitable food assistance have existed for a long time, during the 1980s and 1990s hunger emerged as a more serious concern across North America (17,55). Due to the economic recession in the early half of the 1980s and a subsequent neo-liberal shift that saw declines in funding for government social service programs, Canada witnessed an increase in the number of individuals experiencing hunger (15,55,56). In response, non-state mechanisms such as charitable agencies began to take on a greater role to improve food access for these individuals, as evidenced by the proliferation of charitable food assistance programs across the nation (15,17,19). Chief amongst this charitable response were food bank programs. Food banks act as food redistribution centres, collecting food donations from the private sector and redistributing them back out to individuals in need. Although initially believed to be a temporary solution to hunger brought on by the recession, their presence has become engrained in the Canadian food system (15). Though food bank use data is not collected in any large national government surveys, Food Banks Canada, an organization that supports Canadian food banks and other charitable food programs, has been collecting use data from participating food banks. They collect information on the number of members accessing food bank programs in Canada in March of each year, and have published these numbers annually in the Hunger Count survey since 2008 (personal correspondence, Diana Stapleton, 2016). Compared to national population estimates (57), the number of individuals accessing these services reflected use by 2.0-2.4% of the population, until 2010, when use increased to 868,000 or 2.6% of the population. This spike in food bank use after the economic crisis of 2008 can similarly be seen in other developed nations across the globe, including the US and the United Kingdom (UK) (41,58,59). In the 2015 annual Hunger Count survey, it was revealed that at least 852,000 people, or 2.4% of the national population, were assisted by food banks in March of that year (20). When accounting for   10 population increases, approximately the same proportion of the population is using food banks today as in the early 2000s. However, these numbers still reflect that food bank services are being accessed by a higher number of individuals than the previous decade (47), and as not all food bank service providers take part in this survey, these reports are considered a conservative estimate of food bank use in Canada. With no federal and provincial policy to ensure food security for Canadians, and inadequate rates of income support, charitable food support has arguably become the default national approach aimed at alleviating HFI (1,15). However, given the charitable food assistance model’s inability to address the income based origins of HFI, and lack of long term evaluation of their services, their capacity to attenuate HFI amongst their members remains deeply contested (15–17,23,26,29). Long-standing critiques of the food bank system have raised moral concerns with the use of food charity as an approach to food insecurity (55). Previous research has indicated feelings of shame and stigma amongst individuals using food banks (24,28,60), and though food banks are not designed or mandated to meet household food needs, their presence creates the impression that something is being done in response to hunger (15,55,56). By decreasing social pressure to fix the underlying financial root of food insecurity, food banks may inadvertently be depoliticizing the governments’ roles in addressing it (15,29,55,56). These concerns combined with increasing reliance on these services speak to the need for better monitoring of the food bank response as a buffer to the experiences of food insecurity for their members. The following sections will outline what is currently known about food bank member characteristics in Canada, how food bank use relates to measures of food insecurity, and current critiques of food bank programs.   2.3.1 Food bank member characteristics 2.3.1.1 Demographic and socioeconomic status  Difficulty in monitoring the number and profile of individuals accessing food banks in Canada is due to the many independent and disjointed organizations involved, each with varying capacity to effectively monitor their members. To rectify this, when Food Banks Canada collects their annual data on usage from these programs, they have also been requesting basic aggregate demographic information. Of the 4,349 food bank operations in Canada affiliated with Food   11 Banks Canada, 1,853 participated in this survey in 2015 (20). Demographic information obtained from food banks is generally sparse, as not all food bank operations have the capacity to collect these data and many organizations opt to avoid requesting potentially sensitive information from their members in order to keep barriers to access low. Of the food banks participating in this survey that do collect members’ demographic data, current information on age range, primary source of income, housing situation (market rental, social housing, homeowners, homeless), and household type (two-parent families, single-parent families, adult couples, single individuals) are available (20,47). The majority of Canadian food bank members in the 2015 sample were under the age of 65 (96.5%), on income support including social assistance, disability related assistance or employment assistance (69%), and living in rental market housing (67%) (20). Although 44% of households assisted were households with children, single individual households represented the largest proportion of food bank members at 46% (20).  These reports depict the characteristics of the wider population of food bank members, and provide data to gauge ongoing national trends. However, these reports are not able to speak to a variety of measures and food bank member situations that would be of interest to independent organizations looking to provide additional services. These include household size, level of education, employment status, household income, and rental costs, and few studies in Canada have sought to determine these specific food bank member characteristics. One study from Toronto assessed female single-parent households and determined that 35% had not completed secondary school and 70% received social assistance benefits as their primary source of income (24). However, the study only recruited a specific subpopulation of food bank members, and cannot be considered generalizable to the larger population of food bank members. A large study in Montreal surveying 490 food bank members found that the gender divide was equal, 54% reported living alone, and although 37% had not finished secondary school, 39% were well educated and had completed some kind of post secondary education. This study also determined that reliance on social assistance benefits was reported by the vast majority of members (87%) and only 3% were employed (23). Both of these studies were conducted in Eastern provinces (Ontario and Quebec). While it is possible that these findings may be relevant to the food bank members in BC, social assistance benefits and housing situations differ between cities and provinces (61). Therefore, additional studies in western provinces remain warranted.    12 In the BC context it is estimated that food banks assisted more than 100,000 people in BC in March 2015. Since the economic crisis of 2008 the number of individuals accessing food banks in BC has risen 28% (20), though population growth has only risen 7.5% over that same time period (62). From the data available from BC food banks participating in the Hunger Count, members were most likely to report being single (52%), receiving income assistance (69.5%), and living in rental market housing (76.4%) (20). One additional study surveyed a convenience sample of 528 food bank members in four cities across BC and found that the majority of respondents were female (69%), and that 42.5% had not completed secondary school (63). However, no information on household size, employment status, sources of income, household income, or rental costs were reported. Furthermore, to date there have been no studies that have looked specifically at food bank members in Vancouver, the largest urban centre in western Canada (64).   2.3.1.2 Health status  Poverty and HFI have been linked with increased prevalence of chronic diseases, including diabetes, cardiovascular disease, and hypertension (7,11,12,65). US studies have reported two times higher odds of having diabetes amongst food insecure populations (12), as well as impaired management of the condition as indicated by two times higher odds of poor blood sugar control (13). This is postulated to be partially related to the instability of the food supply over the course of the month, as those with low incomes have been noted to have a 27% increase in hospital admission rates for hypoglycaemia at the end of the month compared to steady rates of admission for those with higher incomes (66). In Canada, comparing National Population Health Survey data from 1994 and CCHS data from 2005, heart disease prevalence was higher among participants with lower socio-economic status when compared to participants in higher income categories, and cardiovascular disease prevalence was noted to have increased by 27% and 37% for the lowest income groups, versus only a 6% increase for those in the highest income category (65). Nationally representative data from Canada has additionally determined that the prevalence of chronic health conditions, such as asthma, bowel disorders, heart disease, hypertension, migraines, mood and anxiety disorders, and pain increase in a graded association to increasing levels of HFI, with those in the most severe category of   13 HFI having a significantly higher prevalence than those in less severe categories (67). It is thought that food insecure groups are likely to be additionally burdened with poorer health due to limited financial resources to ensure adequate nutrient intakes and health management (7,14,68). However, this relationship is also likely to be bi-directional, as individuals with poor health or conditions that limit their capacity to hold stable employment and obtain adequate incomes may also be at higher risk of food insecurity (67), and potentially food bank use.  Currently, little data exist which measure the health status of food bank members. This is largely due to lack of data on food bank use from national health surveys in Canada, and because food banking services have not focussed on health support in the past. One large national survey of US food bank operations determined that 34% of households accessing these services reported a member of the household who had diabetes, and 59% of households had a member with hypertension (59). One Canadian study from 1998 assessing health status amongst food bank members in Quebec found that 25% of food bank clients reported poor health, with physical problems (11%) and chronic medical conditions like hypertension and diabetes (9%) being the top reported health issues (23). A more recent 2012 study of four food bank operations in BC noted that 34.9% of food bank members reported their perceived overall health to be fair or poor (69), which was higher than the 10.7% reported by British Columbians during the same year (70). These findings indicate that health concerns are prevalent amongst food bank members. However, information on the specific health afflictions experienced by this population, including participant reported challenges and prevalence rates of chronic diseases or mental health issues, are not currently available. If food banks are interested in linking relevant services with their programming, a better understanding of the key health issues experienced by food bank members would improve the appropriate selection of partners.  2.3.1.3 Household food insecurity status As described above, health issues have been associated with food insecurity. However, it has further been determined that as food insecurity becomes more severe, the odds of experiencing chronic illness (12,67) and utilizing health care services increase (14). Canadian studies have additionally found that as food insecurity becomes more severe, total intake of energy, protein, iron, magnesium, and zinc decrease, thought to be due to larger reductions in   14 food quantity and quality, and meat and alternative intake (8,71,72). These higher-level decreases in the most severe categories of food insecurity may result in higher prevalence of nutrient deficiencies. Together, these findings provide evidence indicating the graded relationship between health and nutrition status and severity of HFI, and point to the greater vulnerability of groups in the most severe category. In large national studies of the Canadian population, severe levels of food insecurity have been most prevalent amongst lone female single-parents, lone adults, and those reliant on social assistance (1); whether or not severe household food insecurity is associated disproportionately amongst specific demographic groups of food bank members is yet unknown. Although all individuals accessing food bank services are likely present due to their perceived food need, for organizations with limited resources, being able to identify specific characteristics that are associated with higher prevalence of severe food insecurity could assist in targeting programs efforts.  In regard to the current understanding of HFI severity experienced by food bank members, no nationally collected data are available that provide an indication of food bank use and HFI. Recent studies of families in low income neighbourhoods in Toronto found that of those who experience HFI, only 20-30% access a food bank (28,68). Indicated as a ‘last-resort’ that a household would only utilize in the direst of circumstances, it is thought that those experiencing increasingly severe levels of food insecurity (i.e. those reporting significant reductions in quality, skipping meals, or going entire days without food) would be more likely to use food banks. These same two studies from Toronto determined that as severity of food insecurity increased, prevalence and odds of using a food bank also increase in a graded manner. In one study, nineteen percent of moderately food insecure families used the food bank and had a two times higher odds of using the food bank than food secure participants, whereas 40% of severely food insecure families reported to use a food bank and had six times higher odds of using a food bank than food secure families (68).  In the second follow-up study, the graded relationship remained evident, with 25% of moderately food insecure families reporting to use the food bank, at three times higher odds than food secure families, and 39% of severely food insecure families reporting food bank use, at four times higher odds (28). Canadian cross-sectional studies looking at HFI amongst groups of food bank members have generally found that food insecurity is highly prevalent, though the prevalence of severe HFI differs across samples (24,63,73). A study which assessed a cross sectional random sample of women using   15 food banks in Toronto reported that 94% experienced food insecurity and 23% were categorized as severely food insecure (24). A recent study that provided a self-administered survey to a convenience sample of food bank members at four food banks in BC found similar results with 95% of members reporting some level of HFI (63). However, reporting of severe food insecurity amongst this group was much more prevalent (68%) than the sample from Toronto. Another report on incident food bank use in Montreal determined that from a random sample of sixteen food banks, 90% of new food bank members were food insecure and 50% were severely food insecure (74). The first study from Toronto was conducted almost twenty years prior to the second two, from BC and Montreal, revealing that there may potentially be an increased prevalence of severely food insecure food bank members accessing these programs. However, the samples used in each of these studies were quite different – the first a random sample of families with children from 21 Toronto food banks (24), the second a convenience sample of members from four BC food banks (63), and the third a random cluster sample of new food bank members across Montreal (74). None of these studies reported associations between different member characteristics and severe HFI, and ongoing assessment of the severity of food insecurity amongst food bank members is warranted.   2.3.1.4 Patterns of food bank use Food banks were originally intended as a short term response to emergency food need in Canada (15). However, in conversation with a staff member at a local Vancouver food bank, many individuals appear to be accessing the service on a regular basis (personal communication, James Ash, January 23, 2015). This is further corroborated by previous research indicating that food banks are being used as a long-term and regular food augmentation strategy for some members (21–24). In regards to length of use, US studies have found that approximately half of food bank members had been using these services for longer than two years (21,22), and 30% had been using food banks for longer than four years (21). A Canadian study from 1999 reported that the median length of food bank use was 2.2 years, and that approximately 72% had been using the food bank for longer than one year (24). In terms of frequency of use, this same study found that members reported accessing food banks an average of 1.3 times per month (24). Another Canadian study from 1998 determined that 23% of food bank members reported   16 attending on a weekly basis, and 44% reported to be using them at least once per month (23). But little data are available from recent Canadian sources to discern what current food bank usage patterns are. It is of interest to determine if those who access food banks in Canada are using them short-term and occasionally for emergencies, or on a more consistent basis to manage long-term food need. Studies that have identified long-term food bank members have found that participants most often reported to have initiated food bank use due to lack of money for food (21–24). Noting a high prevalence of unemployment in some of the studies, this was also considered to be a contributing factor to ongoing use (21,23). A study from the US found that many members using food banks also reported participation in food stamps or other government food support programs, suggesting that food banks are being used by households as an ongoing measure to supplement government programs that are not providing sufficient assistance to meet basic needs (21). Similarly in Canada, a high proportion of food bank members receive income assistance (20,23), and food bank use was positively associated with receipt of income assistance amongst low income households (68). However, none of these studies have verified with members if and why they view the food bank as a long-term resource. A large national US survey of food bank members determined that 63% plan to get food from these services on a regular basis (59), but this survey did not provide reflections on why members planned for this. Although evidence is mounting that long-term use is linked to unemployment and inadequate government support, a member framed understanding of the role food bank organizations play in their lives and the underlying issues that result in an ongoing requirement of these services is needed.  2.3.2 Evaluating the food bank response to household food insecurity Charitable food assistance has been argued to have become the accepted norm to address food insecurity for Canadians (15). This is evidenced by health care and social service providers being reported to refer low-income individuals to these programs as they recognize the food bank as one of the only alternatives for food attainment for people without financial means (29,75). There also remains an assumption that food banks are an appropriate response to the problems of hunger and severe food insecurity, even amongst community members working with food insecure populations (26). However, evaluation of the use of food bank services with HFI severity is limited, and only two Canadian studies were found that assessed this. A longitudinal   17 study of a low-income neighbourhood in Toronto found that 76% of households that were severely food insecure at baseline remained severely food insecure at follow-up despite having accessed a food bank in the interceding two years, indicating that food bank use was not associated with decreased prevalence of severe food insecurity (28). A more recent study conducted amongst incident Montreal food bank members found that the odds of reporting severe food insecurity was significantly lower nine months after their initial sign up to the food bank (74). This suggests that for new members, severity of HFI may be attenuated. However, despite the statistically significant decrease, the prevalence of severe HFI did remain high at the nine month follow up period (39%), only decreasing by eleven percentage points overall from 50%, indicating that use of the food bank does not adequately ameliorate severe hunger for many. Furthermore, losses to follow up were high and the study did not include longer-term members, who may potentially be more entrenched in poverty and food insecurity. Of note, both of these studies used self-reported food bank use, or categorized food bank use as a binary yes or no, not taking into account length or frequency of use and their associations with severe HFI. If information on length and frequency of use were available, additional questions surrounding the capacity of the food bank to buffer HFI could be answered. It would be of interest to see if there are specific usage patterns of food bank members - higher frequency of use, or long-term use – that are associated with lower prevalence of severe HFI than other patterns. Ideally, repeated measures of HFI would allow for the best evaluation of the relationship between frequency of food bank use and HFI. In the absence of repeated measures of HFI collected in this study, looking retroactively at past frequency of use may be able to assist in this assessment, to explore if there are any associations between frequency of food bank use in the past year and severe HFI.  2.3.3 Experiences and challenges with food bank services 2.3.3.1 Food quantity, quality and preferences Multiple challenges affect the capacity of food banks to serve those in need. As they are reliant on variable and limited amounts of donations, food banks often offer restricted amounts of food, just a few times per month to their members (17). Canadian studies have found many food bank organizations limit the amount of food they provide when the number of individuals requiring their services rise or their donations fall – indicating that quantity of provisions are not   18 assured (17,27). It is reported that food banks in Canada offer anywhere from one to six days’ worth of food for their members per month, though studies have noted that food bank organizations may overestimate what is actually provided (76,77). Monthly pre-packaged food bank provisions in Ontario were found to contain a mean of six grain servings, two fruit and vegetable servings, and less than one meat and dairy serving per individual served, despite their intentions to provide three days’ worth of food (77). A study analysing the nutritional content of food provisions from a Calgary food bank found that provisions were lacking in several macronutrients and micronutrients when compared to the four days’ worth of nutritional requirements the food bank estimated they provided (76). A recent survey of food bank operators determined that 72% reported their members needed more food than they could provide (17).  Reliance on donations also limits food bank organizations’ abilities to be selective about the food they collect, and they often receive foods that are past their sell-by date and of poor nutritional quality (17,19,27). As operational goals have historically been to offer as much food as possible, food banks have often focused on food quantity, with less concern on the overall quality of the donated foods they accept and provide (1). Most data on the impact that food banks make is focused on the total food weight provided, which speaks nothing to the nutritional content or quality of the food items actually received, or whether these provisions are meeting their members’ needs. As reported in conversation with a local food bank director (personal communication, Diane Collis, March 2015), in the past, weight from cases of soda would be included in their measurement of the food banks’ impact. Previous studies have additionally found that Canadian food bank members have indicated the questionable safety and quality of the food that they obtain from local food banks, and noted that they do not cater to their specific cultural or personal food preferences (21,28).  This disconnect between provided services and members’ food need suggest that food banks are not adequately addressing the hunger and food requirements of those who access them (27). A greater understanding of participant experiences with hunger while using food bank services, and their estimation of whether or not food bank provisions are or can meet their household food needs, will provide a stronger understanding of the current capacity of food bank organizations to address hunger. Additionally, to promote participant directed change, a greater understanding of food bank members’ food preferences and needs will assist food bank organizations to move forward in a manner which is most relevant for their members.    19 2.3.3.2 Operational barriers Food banks experience a large number of operational barriers that can limit the accessibility of food bank services. Firstly, to account for all the collection, storage, transportation, and distribution of food, food banks require a large amount of support from their communities to coordinate (17,78). This includes both financial support and a huge quantity of volunteer hours. Secondly, due to staffing and program space availability, they are often only available at specific locations and for a limited number of hours each week or month (17). These restrictions on availability may also be due to the need to ration the available food amongst members given limited quantities of donated food (17,27). Unfortunately, by limiting the number of hours, days, and locations that food bank services are available, individuals who could benefit from these services may be impeded from accessing them. This was suggested in a recent study with food insecure households in Toronto, where 19% indicated they had wanted to use a food bank but reported barriers to access such as limited food banking hours, lack of transportation to get there, and long line-ups (28). Thirdly, the design of food bank service delivery has been reported to limit the ability of these organizations to provide dignified food access. These concerns include having to stand in line, being watched over or treated poorly by volunteers, receiving poor quality food, and not having a choice over the items taken home (21,28). Despite finding severely food insecure households had higher odds of using food banks, only 40% of this severely food insecure sample reported to have used them, indicating that many households with high levels of food need are not electing or are limited from using food bank support (28,68). Together, these operational barriers suggest substantial limitations in food banks’ ability to meet the needs of food insecure Canadians.  Due to these findings, as well as the stark difference between the number of Canadians reporting food insecurity and the number accessing food banks, food bank use has been found to be a poor indicator of HFI (79). This implies that surveying food bank members will only provide information on one sub-sample of the larger food insecure population. Nevertheless, developing a better understanding of food bank members’ experiences and challenges using the food bank, and their vision for future updates will help to indicate operational changes that food bank organizations can undertake as they move forward. Combatting some of these issues may create discernible improvements that will make their programming more approachable and relevant for the wider food insecure population.    20 2.4 Food bank transformations  Food bank organizations have begun to transform their services to address the previously reported deficiencies and concerns that have been associated with their programs. In Toronto, a food bank organization called The Stop reinvented itself from solely an emergency food distribution centre to a Community Food Centre (80). This organization focuses on community building by creating a dignified space to access food and participate in food based programming, including community gardens, cooking programs, and nutrition education (48). They report to offer not just food banking services, but a variety of programs to “help people meet emergency food needs with dignified, respectful services, all centered around healthy food” (31). Results of their annual cross-sectional program survey determined that 45% of participants attributed improved self-reported physical health to participating in the organization’s programs, 56% reported their ability to cope with stress had improved, and 65% had learned new things about choosing healthy foods (81). Another novel food bank program in Connecticut, named Freshplace, introduced client selection of items to be taken home, regular monthly meetings based on the principles of motivational interviewing, and targeted referrals to other community programs (25,30,82). When this program was launched, researchers conducted an intervention trial where members were randomized to continue accessing food through a traditional food bank program or the new Freshplace model. Longitudinal data showed an improvement in self-sufficiency as well as an increase in fruit and vegetable intake for those participants randomized to Freshplace (82). These findings indicate that new approaches to food banking may be beneficial in supporting health.  2.4.1 Community Food Security Continuum framework Using the language from the HFI Action framework previously described (16), these organizations are aiming to unite the charitable model with elements of the household improvements and support model. This combined model aims to combat food insecurity through a variety of avenues including dignified food access, skills training, and social cohesion (48). This advancement of the charitable model is further illustrated in the community food security continuum.  Originally developed by MacRae et al in the discussion of food security and sustainable agricultural practices, the community food security continuum aimed to provide a framework to   21 organize strategies and policies that agricultural agencies and government could use to effect system change (83). They conceptualised this progress as moving across a continuum, including activities that could be designated within three overlapping stages: efficiency, substitution/participation, and re-design. Acknowledging that greater community food security requires a full system approach, this framework has been adapted by others, including food policy councils, nutritionist councils, and health educators, to reflect activities and practices that different groups can undertake to build effective food systems change and greater food security (53,84–86). The efficiency stage outlines changes required for current conventional measures to improve their impact on food security issues. In the substitution or participation stage, additional measures are brought in to assist in building community-level capacity to manage the food security issue. At the re-design phase, the causes of the issues or underlying factors contributing to the problem are recognized and addressed, to affect long-lasting food security. The overall trajectory of the community food security continuum framework is towards eventual food systems redesign where incremental changes occur in the community’s response to food insecurity across all stages until capacity, advocacy and policy efforts are set to ensure food security at the broader community and government level (83,85). Using the issue of hunger and HFI, the stages of the community food security continuum can be tailored to reflect the role that food banks have to play, both as a major component of the efficiency stage and as an agent in moving this transition forward (Figure 2-2). Strategies for food banks to take part in this transition have begun to be outlined and put into practice by some organizations. As reported above, Community Food Centres Canada assists to support movement from an efficiency stage entity to one that reflects the participation stage through the addition of community gardens, cooking programs, and nutrition education (48). Furthermore, facilitating programs that provide training and encourage community advocacy amongst members, as well as framing their discussions on HFI and food bank access using a rights-based approach, reflect activities that encompass the re-design phase (48). However, given the novelty of this undertaking, there remains a scarcity of research pertaining to the process of food banks advancing across the community food security continuum. As food bank organizations begin to reflect and adjust their services, creating an account of these activities and assessing their outcomes remain important for sharing knowledge and providing evaluation of this movement.    22  Figure 2-2 Community Food Security Continuum framework, adapted to address HFI   2.4.2 Vancouver context In 2012, food insecurity in Vancouver was estimated to affect 10% of households (1). The Greater Vancouver Food Bank (GVFB) has served theis community for the past thirty years providing donated and purchased food items to food insecure individuals and families through thirteen food bank depots and just under 100 partner agencies (87). They presently provide food for more than 6,500 individuals at their thirteen sites across the Greater Vancouver Regional District (GVRD) each week (87). Aligning with the Vancouver Food Strategy, a framework developed by the Vancouver Food Policy Council in 2013, the GVFB is interested in adjusting their programs to “facilitate the transition from a charitable food model to one based on principles of a just and sustainable food system” (54). The GVFB determined that aspects of their traditional food provision model contained many of the issues reported from previous food bank research, such as limited food quantity and quality, restricted operational hours, line-ups, and lack of choice. Their initial are to provide increased access to healthy foods, and foster “a path towards food security” (87), and the organization recognizes that in order to ensure that they are providing relevant and meaningful updates to their services they must first understand more about, and work with, their member community (personal communication, Aart Schuurman-Hess, January 2015).     23 2.4.3 Community based participatory research Effective solutions to community food security issues are best achieved using participatory approaches that include the affected groups’ own perceptions and solutions for the problem, as they provide greater agency throughout the process and are better attuned to meet the groups’ needs (88). To this end, academics from the University of British Columbia (UBC) and Simon Fraser University (SFU) were invited to partner with the GVFB to help them create a collaborative research program following the guidelines of community based participatory research (CBPR) (89–91). A CBPR orientation encourages participation of community members in the research process, to promote community driven issue selection (89,91). This approach also follows a pragmatic perspective, seeking to understand and be responsive to the current situation, and develop research methods that can be tailored to this need (92). To date, in order to keep barriers-to-access at a minimum, the GVFB has requested only basic information from their members. Therefore, one goal of this research was to collect additional demographic information and feedback to develop a better understanding of the individuals who use their services. This evaluation was also to be a means of enhanced participation and empowerment for those affected by food bank services, to ensure that the organization was being responsive to the concerns of their members (93–95). Therefore, additional goals included providing space for their community of members to self-identify problems they currently face, both in their daily lives and with food bank services, and suggest strategies or recommendations that the food bank should prioritize in their service updates to better support their members.   2.4.4 Mixed methods research  Dictated by the CBPR focus, and the desire to understand more about not only who uses food banks but what their experiences and visions for food bank services are, a mixed methods study was determined to be the best approach. To date, no published mixed method studies of Canadian food bank members were found. In conducting a literature review on this topic, one process evaluation conducted at a university campus-based food bank was found that used surveys and focus groups with different food bank stakeholders (96). Quantitative data using Likert scales to measure service satisfaction were collected from both food bank members and staff, but qualitative data requesting information on how food bank services could improve were   24 only conducted with food bank staff. Another two studies were also found that employed both quantitative and qualitative data, but the samples recruited were from food insecure Canadian populations and not necessarily food bank members. One of these studies recruited food insecure households and included semi-structured interviews to determine socio-demographic characteristics, household food insecurity, participants’ self-perceived situations that lead to food insecurity, and assets that assist with combating food insecurity (26). However, this study did not seek to specifically evaluate food bank services. Another study that recruited low-income families conducted semi-structured interviews with both quantitative and qualitative questions (28). This study collected information pertaining to socio-economic factors, household food insecurity, and food bank use in the past year (yes/no), and also asked participants who did not use food banks to provide reasons for not using them. This provided valuable insight into understanding explanations for why food insecure families choose not to use food banks. However, as with the previously mentioned studies, a mixed-method framework was not used to combine the two types of data, and none worked exclusively with food bank members.  A mixed methods approach could be an important tool to integrate and draw interpretations, and better understand food bank members’ experiences, as it combines the strengths of both quantitative and qualitative methods. Quantitative data allows for the development of a descriptive profile from a broader group of food bank members, and for examinations of associations between these characteristics and food insecurity status. Qualitative data provides opportunity for members to identify their own challenges and describe how they envision the food bank improving (93,94) – two major goals of this community-based study (92,97). This approach would also foster improved engagement with the GVFB member community, allowing members the opportunity to communicate their experiences with researchers and the GVFB through two alternate methods.  2.5 Objectives  Study objectives were based on issues identified through discussions with our food bank community partner and the previously reported literature review. Characterizing the initial exploratory phase of this community based research partnership, study objectives were meant to be exploratory and can be divided into two areas of focus: 1) to develop a profile of current food   25 bank members, and investigate the determinants of household food insecurity among this group; and 2) to determine how and why members use the food bank, and explore their current experiences and preferences for food bank services. Each area of focus was addressed with an individual study.  2.5.1 Study 1   To date, Vancouver food banks have collected very little information about their members, and the development of a descriptive profile was desired. Furthermore, given a lack of evaluation, a better understanding of the role food bank use plays in buffering food insecurity remains an important area of inquiry. Therefore, the objectives of this study were as follows:  1) To develop a descriptive profile of a sample of current GVFB members, including an examination of their demographic characteristics, socio-economic status, health status, patterns of food bank use, and household food insecurity status.  2) To explore determinants of severe household food insecurity for a sample of GVFB members.   Described in chapter three, a survey was used to collect a baseline assessment of members’ characteristics from a convenience sample. Food bank records were used to collect usage statistics for each participant. Statistical analyses were used to determine if any of these characteristics were associated with the most severe form of household food insecurity.   2.5.2 Study 2 More individuals are using food banks than ever before and evidence suggests that some use them as a long-term strategy to obtain food. However, multiple barriers have been revealed which potentially limit these organizations’ ability to support food insecure populations. As food bank organizations begin to place more attention and resources on adjusting their services, improved understanding of how food bank members view these services is required. Determining if and why food bank members view these services as a long term resource, and enhancing our understanding of their current experiences and visions for improved services,   26 remain important pieces to inform future program planning. Objectives for this study were as follows:  3) To determine to what extent food bank members view the food bank as a short or long-term food augmentation strategy and explore self-perceived challenges that result in requiring food bank services long term.  4) To determine how food banks can improve service provision by exploring food bank members’ current experiences and challenges with food bank services, and their vision for change.   In order to bring greater insight to participant responses, and given the gap in mixed methods literature among food bank members, a convergent mixed methods design was used to answer these objectives. Both quantitative and qualitative data were collected in parallel, analysed separately, and then combined to address our research objectives. For objective three, both surveys and focus group questions requested participants to indicate whether they planned to use food bank services in the future and focus groups posed additional questions to elucidate why participants saw the food bank as a short or long-term strategy. Socio-demographic data collected in the surveys that related to focus group responses were then compared to determine if views expressed by participants were representative of trends in the larger food bank population. For the fourth objective, both survey and focus group questions explored opinions and attitudes about food bank services, and preferences and vision for the future. The two forms of data were then converged in order to bring greater insight to food bank members’ experiences.   2.6 Summary Food banks have existed in Canada for over thirty years and are currently being used by more individuals than ever before. Although they are on the forefront of the approach to alleviate food insecurity in Canada, food banks have been found to have substantial barriers that limit their ability to provide access to adequate food for those that need them, and their capacity to alleviate food insecurity and hunger amongst their members remains questioned. Recognizing   27 these concerns, food bank organizations are interested in adjusting their services to better support the needs of their members.   The purpose of this thesis is to contribute to the evidence base required by the GVFB and other food bank organizations to inform future programming direction by building a greater insight into the situations and experiences of the food bank member community. A mixed-methods CBPR approach was proposed to promote greater understanding and engagement among food bank members, the food bank organization, and the research team. Findings will offer valuable insight into practices and policies envisioned by a vulnerable HFI-affected group that will encourage the movement of food bank organizations and other interested agencies across the community food security continuum towards improved community food security.       28 Chapter 3: Food insecurity in Greater Vancouver: exploratory findings from a community consultation with food bank members  3.1 Introduction Food security describes a situation where “all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food which meets their dietary needs and food preferences for an active and healthy lifestyle”(32). In 2012, over 1.7 million Canadian households (12.6%) experienced household food insecurity (HFI), or limited access to nutritionally adequate, safe, and acceptable food (1). In the western world this lack of access is largely tied to economic factors, including insufficient purchasing power and poverty (5–7,15). Resulting from an inability of a household to afford all of the basic costs of living, expenditures on food purchases diminish as this is one of the most flexible components of the household budget (55). Given the strong links between HFI, poor nutrition, health concerns and disease prevalence (6–8,65,98), improving food access is crucial for improving health outcomes for low-income households.  Charitable food assistance, namely food banks, are on the forefront of the Canadian approach to HFI (15). Food banks primarily act as food redistribution centres. They collect food from the community through reclamation from food producers and retailers, and charitable donations from the public, and then distribute these items back to individuals in need (29). Food banks proliferated in the 1980’s as an emergency response to help Canadians during the 1981-1985 economic recession (55,56). However, what was intended as a temporary solution is now widespread, and embedded among a variety of services for low income Canadians (15). In the absence of government action towards alleviating food insecurity, the number of agencies offering food bank services are on the rise (17), and are argued to have become the “de facto” policy in the fight against food insecurity in Canada (15,29,36).  In 2015 Canadian food banks reported the highest number of users on record, serving over 850,000 people monthly (20). In British Columbia (BC), where 11.8% of households are reported to be food insecure (99), over 100,000 people accessed food at food banks in a single month in 2015, representing a 28% rise since 2008 (20). These data suggest that charitable food provision interventions are becoming a necessity for an increasing number of households.   29 However, despite growing use, currently little is known about these programs’ capacity to impact food insecurity and it has been argued that the “public legitimacy” of food banks, due to wide civic support, has allowed charitable food to be framed and accepted as an appropriate and effective solution to the problem of immediate food need (15,26). Yet, there has been little known evidence of their ability to alleviate HFI and hunger, prompting a call for greater monitoring of the food bank response (15,16).	  	  HFI status amongst food bank members is an area of limited study. HFI is experienced across a spectrum (1), with severe levels of food insecurity associated with larger declines in nutrient intakes (8,71) and higher prevalence of chronic health issues and health care utilisation (12,14,67), indicating elevated vulnerability for individuals who experience this. Prevalence rates of severe HFI amongst food bank members have ranged from 23% to 68% (24,25,63). Although one study from the US reported that food bank members under sixty years of age had higher odds of being food insecure (25), no Canadian studies have sought to determine if specific food bank member characteristics are disproportionately associated with the most severe characterisation of HFI. In large national studies of the Canadian population, severe HFI has been most prevalent amongst female lone-parents and lone-individuals households (1). Whether these or other characteristics are associated with severe HFI amongst food bank members is yet unknown. Additionally, it remains unclear how food bank utilisation rates are associated with HFI. Studies assessing member-reported food bank use have indicated ongoing and regular participation in food bank programs amongst some members (21,23,24), but only 1 study from 1998 assessed frequency of food bank use with HFI status. It determined that amongst families with children, no correlation was found between frequency of food bank use and HFI status (24). This current study sought to determine whether different food bank usage patterns are associated with higher or lower prevalence of specifically severe HFI amongst food bank members. This study reports on exploratory data collected while developing the process and tools needed to generate an evidence base for a Vancouver area food bank. This food bank organization has requested only basic information from their members in the past. One reason for this is by limiting the amount of personal and sensitive information requested they are able to keep barriers-to-access at a minimum for members, who may find sharing this information invasive or discriminatory. However, they recognized that in order to ensure they are providing   30 relevant and meaningful updates to their services, they must better understand their member community. The objectives of this study were: 1) to create a descriptive profile of a sample of GVFB members, including their socio-demographic characteristics (gender, age, household size and structure, education, employment status, income, source of income, and rent cost), length and frequency of food bank use, and HFI status (food secure, mildly food insecure, moderately food insecure, or severely food insecure); and 2) to explore whether potential characteristics, including food bank usage patterns, are associated with the most severe form of HFI. The results contribute to an understanding of who uses food banks in Vancouver, and how food bank use and other socio-demographic factors associate with severe HFI amongst this subgroup of food bank members. These findings will add further evidence to the discussion regarding food bank use as a buffer from the experience of severe HFI, and can inform future food bank programming and feasibility of a future evaluation study.   3.2 Methods We used a community based participatory research (CBPR) approach to the study which encouraged participation of community members in all aspects of the research process in order to tailor the research to meet and be responsive to community need (89,91). Alongside a team of academic researchers, members of the food bank management team and volunteer team were involved in the research question development and design of this study. Additionally, a food bank member was recruited during the design phase to fill the position of peer research assistant (PRA). This PRA provided feedback regarding the design and implementation of the study, and supported the research team by playing a major role with community engagement, participant recruitment, and data collection. This study was non-experimental and descriptive, and used quantitative survey methods to address our research objectives. The survey format was selected as they are routinely used to obtain information from a sample of members, to determine incidence and distribution of characteristics, and their associations with other variables (100).   3.2.1 Participant recruitment Three food bank site locations were selected as recruitment centres for the study using non-probability sampling from a total of thirteen sites. Our community partner identified these   31 sites for this exploratory study due to the capacity of these sites and their volunteer teams to support the research team’s activities. These three sites represented three distinct neighbourhoods across the GVRD, and reflected small, medium, and large site sizes in terms of the number of members served each week (see Appendix A).  As an exploratory study that aligned with our CBPR strategy, the goal was to engage with the food bank member community using low-pressure tactics over a set time frame, and no formal power calculations were undertaken. Food bank members were recruited via convenience sampling in order to encourage inclusivity in the process and allow for participation in the study from any interested food bank members. Outcomes in recruitment speak to the feasibility of obtaining adequate participant recruitment using this sampling method for future longitudinal research and evaluation.  Each of the three food bank sites were open once per week, and recruitment was undertaken at each site during normal operating hours over a seven week period between July and September 2015. The research team set up an information booth at each of the sites over this seven-week period. Members were informed of the study through the aid of a poster, as well as research staff providing brochures and educating members about the study as they stood in line waiting for the food bank to open. If members were interested, they were directed to the information booth where members could obtain further information about the study to determine if they were eligible to participate. Eligibility criteria for the study required participants to be an adult (>18 years old) member of the food bank, with the ability to communicate in English, and without a cognitive impairment affecting their ability to provide consent. Members who met the criteria and desired to participate were provided with a consent form, which they signed prior to completion of the survey. The UBC Behavioural Research Ethics Board, and the SFU ethics board approved the protocol for the study (H15-001180). Upon completion of the survey, participants were offered a $5 honorarium or two bus tickets valued at $5.50 for their time.  3.2.2 Survey The research team met with staff members from the food bank to determine key areas of interest that would assist to address the organization’s major knowledge gaps for service provision. Survey questions concerning socio-demographic characteristics, including gender, age, household size, education, and employment were adopted from validated Canadian   32 questionnaires used in large national surveys. These include the National Household Survey (101), the CCHS (70), and the General Social Survey (102).  When no previously used questions or tools of appropriate length could be found to address the constructs of interest, the research team developed additional questions. These included questions designed to determine household structure (age and sex of other household members, and relationship to participant), monthly household income range, household income sources, monthly housing cost range, food access points, adequacy of food obtained at the food bank, and change in hunger since first using the food bank. For household income ranges, cut-offs were used to reflect incomes below basic income assistance rates and above measures of low-income. A low range of 0-$599 was selected as this reflected incomes below the social assistance rate for a single individual in Vancouver ($610/month)(103). Then, maintaining a consistent interval range of $600, an upper income range cut-off of $1800/month was also selected, due to its approximate alignment with the low income cut-off ($20,160/year) for single adults living in Vancouver (104). See Appendix B for final survey. The 18-item HFSSM from the CCHS was used to assess food insecurity status (39). The module was developed and validated through the process of identifying a particular set of conditions, experiences, and behaviour patterns that characterise a household’s experience with financial access to food. It recognizes that food insecurity is experienced on a spectrum, and as the number of affirmative responses to the survey questions increase, HFI categorization increases in severity. For this study, HFI categorization followed the same method as outlined by the PROOF research group in Canada, which recognizes four classifications of HFI: a) food secure, where households have adequate financial resources to access food; b) marginally food insecure, characterised by the psychosocial aspects of inadequate access to food, such as anxiety about running out of food; c) moderately food insecure, where households are reducing the quality of foods with potential reductions in quantity of food intake in order to make foods last; d) severely food insecure, which includes reductions in food quality and quantity, including skipping meals, experiencing hunger, losing weight, and/or potentially going for entire days without eating.(1)  The HFSSM poses a series of questions in three stages to assess a household’s financial access to food over the past year. The staged progression provides questions that are increasingly reflective of situations known to be associated with more severe levels of HFI. To reduce   33 respondent burden, if no affirmative responses are provided in one of the stages the survey will not progresses to the next stage. A maximum of ten questions is provided to all participants, with an additional maximum of eight questions asked of families with children. The types of questions asked followed the format “The food you bought just didn’t last, and there wasn’t any money to get more”. Affirmative responses to limited food access included any “Yes”, “Often true”, or “Sometimes true” response to the question. Negative responses include “No”, “Never” and “Only 1 or 2 months” in the past year. All affirmative responses are coded as one, and all negative responses are given a zero, for a maximum score of ten for the adult scale, and eight for the child scale. Following scoring procedures for the adult scale, “Food Secure” contained zero affirmative responses, “Marginal Food Insecurity” had 1 affirmative response, “Moderate Food Insecurity” had two to five affirmative responses, and “Severe Food Insecurity” had six to ten affirmative responses. For the child scale, “Food Secure”, contained zero affirmative responses, “Marginal Food Insecurity” had one affirmative response, “Moderate Food Insecurity” had two to four affirmative responses, and “Severe Food Insecurity” had five to eight affirmative responses. If a participant’s responses for the adult and child scale did not fall within the same category of food insecurity, the most food insecure group was used to designate the household (39) (Table 3-1).   Table 3-1 Household food insecurity categorization scoring Household food insecurity category Experience HFSSM score  (adult and child scores) Food secure Adequate financial resources to obtain food 0/10 and 0/8 Marginal food insecurity Worry or anxiety about running out of food 1/10 or 1/8 Moderate food insecurity Decreased quality and balance and/or decline in quantity 2-5/10 or 2-4/8 Severe food insecurity Decrease in quality and quantity, skipping meals, to potentially going entire days without food 6-10/10 or 5-8/8  Once a complete survey question list was developed, all questions were further assessed by content experts on the research team (n=6), food bank management staff (n=6), and a peer research assistant to evaluate content validity (100). Following best practice for survey administration, members of the research team then reviewed and discussed the resultant survey to determine if any further specifications should be noted within the survey (100).   34 Specifications were added that would assist the interviewer to explain or clarify any confusing questions that were found to occur during the piloting phases. The survey was further piloted with food bank staff (n=14) and food bank members (n= 5) to ensure appropriateness of question selection and wording for the population of interest.  The survey was developed and hosted using FluidSurveys™ a web-based survey tool made available through UBC Information Technology (105). This survey tool was utilised for ease of survey administration and data collection, and provided a variety of features including: off-line survey administration, text boxes to allow for instructions on survey administration and question specifications or probes, note sections to provide space for qualitative responses, ‘required’ questions to ensure that all questions were answered (i.e. – ‘prefer not to answer’ option used), multi-module format allowing for skip structures, options to skip pages or return to previous pages, and a variety of question delivery formats (multiple choice, yes/no, drop down, matrices) to suit all question types. (See Appendix B for final survey)  3.2.3 Food bank organizational records Food bank use data were collected from a member management system (MMS) utilised and stored by the food bank organization to monitor member access to their programs. All survey participants were requested to provide their membership number. These numbers are linked to a membership card that is given on the first day of sign up to the GVFB, and that is swiped each time the member accesses food bank services. All data are stored in the food bank’s MMS database, and were collected by the research team for all consenting participants. At the time of survey administration, we were not sure if we would be able to access organizational records to obtain length or frequency of use data for all participants. Therefore, we additionally included survey questions that requested self-reported a) length of food bank use, and b) estimated visits to the food bank over the past quarter. Length of food bank use obtained through the MMS was determined based on date of initial sign up. However, the initial sign-up date was found to be inconsistently reported, so the date used was either the sign-up date or the first site visit associated with the membership number, whichever was earliest. Working back from the study’s end date of September 30, 2015, each date was given a number designating the total number of years a participant had been a   35 member. Participants were then coded as: “New users <1 year”, “Medium term users 1-5 years”, and “Long term users ≥ 5 years”. For frequency of use, date-of-access data was retrieved from the MMS database to include each participant’s food bank visits between October 1, 2014 and September 30, 2015. The time frame of the year preceding the study was used to align with the time frame ‘over the past year’ indicated throughout the HFSSM module (39). The GVFB provides food weekly to participants, but is closed one week each month when income assistance cheques are distributed, and on holidays. Therefore, participants could have visited a minimum of one time up to a maximum of forty times over the past year. Average frequencies of monthly visits over the past year were coded as “Low use <1 visit/month”, “Medium use 1-2 visits/month”, and “High use >2 visits/month”. Through these same food bank organizational records we were able to access basic demographic information for all unique members accessing the three food bank sites over the study period (gender, household size, frequency of use, length of use). These statistics were used to compare our sample with the larger population of food bank members on these four available variables.      3.2.4 Data collection Survey data collection was conducted using a study protocol manual developed by the research team with input and feedback from the food bank’s management team, site coordinators, and PRA (Appendix C). Study protocols included step-by-step guidance for all components of data collection, including: participant recruitment, obtaining participant consent, and survey administration. To ensure the wellbeing and dignity of all food bank members and participants, additional protocols included guidelines for emotional and physical safety during field research (100,106,107). This protocol was developed with the assistance of a food bank staff member who provided additional situational training in a workshop format for the research team prior to engaging with the community. This workshop outlined practical skills to safely respond to challenging behaviour and manage sensitive situations, to promote care of members and safety for all throughout the data collection period.  Trained interviewers administered an electronic survey with participants in a private space on site, or over the phone if the participant preferred. Interviewer administration of the   36 survey was selected to promote rapport building between food bank members and the research team, and to ensure that English reading level of the participants would not affect survey results (100). This method of data collection is additionally known to improve response and completion rates of surveys by reducing the number of non-responses (100), and would also provide an opportunity for interviewers to collect additional qualitative feedback throughout the survey for some questions. For example, as health conditions amongst food bank members were unknown, a specification area was provided where interviewers could report on all health issues the participant reported. In order to promote consistency in survey administration, training was provided to all research team staff. Interviewers were informed of the study purpose and provided with a protocol and procedure manual and a copy of the survey for self-study before the official training day. Interviewers witnessed one demonstration interview and practiced working through the survey on two training days with research team staff and one piloting day with food bank staff. To improve reliability of the data collection procedure and avoid biased answers, interviewers were instructed to respect best practices by following the questionnaire wording and order exactly, reading the entire question and verifying participant responses if unclear, and remaining neutral to responses (100). To maintain quality control throughout the data collection period, the research team additionally had daily check-ins and weekly reviews to discuss their experiences on site and review any issues or concerns regarding survey administration.  3.2.5 Analysis Descriptive statistics were used to examine the sample of food bank members. Frequency and prevalence of participant characteristics were determined. Cross tabulations and Fisher’s exact tests were used to describe the association between severe HFI and socio demographic variables or food bank usage. Individuals reporting all other levels of food insecurity (secure, marginal, moderate) were used as the reference category for Fisher’s exact tests. The selection of Fisher’s exact tests versus other statistical analyses (Chi2, logistic regression) to measure associations was due to the small sample size, non-probability sampling method, and non-equal distribution of variables resulting in small expected cell counts in contingency tables (108). An alpha level of 0.05 was selected to indicate statistical significance for Fisher’s exact tests. All data were managed and analysed using STATA (StataCorp LP. Version 12.0, 2011).    37 3.3 Results 3.3.1 Sample characteristics Of the 1085 unique members who accessed the three food bank sites over the seven week recruitment period, 84 members provided consent to participate in our study. Of these 84 members, two did not come back to the research booth during their scheduled survey appointments and either did not leave a contact number (n=1) or did not return our calls (n=1). Five members who signed up for phone interviews were also unable to complete the survey due to incorrect contact information being provided (n=1) or failing to return the call of research staff after three contact attempts (n=4). The final survey sample size was n=77 participants. Although a true participation rate was unable to be calculated, as we did not ask each and every member to participate over the seven-week period, a conservative estimation of survey participation was 7.1% given 77 participants were recruited from a sampling frame of 1085 unique members. Key demographic characteristics of the sample are presented in Table 3-2. Gender was approximately evenly distributed, with slightly more male participants at 59%. The majority of this sample lived in adult-only households (90%), and many lived alone (58%). Although 84% of the participants were of government-recognized working age (<65 years old) only 19% of the sample reported being employed. The majority of participants received government based social assistance (84%), including income assistance/welfare (50%) and/or disability benefits (61%). Most participants reported very low incomes below $1200/month (68%), and the vast majority of the sample reported incomes <$1800/month (91%). Almost all participants (96%) were renting their homes, and 45% reported paying >$500 in monthly rent costs. When looking at other locations that participants obtained food from, 49% reported using free meal programs and 49% received food from family or friends. Very few reported using gardens (26%) or community kitchen programs (14%). A complete list of participant characteristics and responses to all survey questions is available in Appendix D.       38 Table 3-2 Food bank member sample characteristics 	   	  Sample	  characteristics	   	  	   n	   %	  Gender	  (n=76)	   Male	   45	   59	  	  	   Female	   31	   41	  Household	  size	  (n=77)	   1	   45	   58	  	  2	   15	   20	  	  	   ≥	  3	   17	   22	  Household	  structure	  (n=77)	   Adult	  only	   69	   90	  	  2	  Adult	  households	  w/	  children	  <	  18	  years	   6	   8	  	  	   Single	  parent	  households	   2	   3	  Education	  (n=76)	   Less	  than	  secondary	  school	  diploma	   31	   41	  	  	   Secondary	  school	  diploma	  or	  higher	   45	   59	  Age	  (n=76)	   18	  –	  39	  years	   13	   17	  	  40	  –	  64	  years	   51	   67	  	  	   ≥	  65	  years	   12	   16	  Employment1	  (n=77)	   Yes	   15	   19	  	  	   No	   62	   81	  Household	  income	  sources2	  	   Income	  support	  -­‐	  all	  types	  but	  pensions	   65	   84	  (n=77)	   Disability	  assistance	   47	   61	  	  Wages	   22	   29	  	  Government	  pensions	  (CPP,	  OAS,	  and	  GIS)	   19	   25	  	  	   Other	  	   12	   16	  Household	  income,	  monthly	  	   $0	  -­‐	  599	   9	   12	  (n=76)	   $600	  -­‐	  1199	   43	   56	  	  $1200	  -­‐	  1799	   17	   22	  	  	   ≥	  $1800	   7	   9	  Home	  ownership	  (n=77)	   Yes	   3	   4	  	   No	   74	   96	  Housing	  costs,	  monthly	  (n=77)	   $0	  -­‐	  500	   42	   55	  	  	   >	  $500	   35	   45	  Food	  access	  points3	  (n=77)	   Free	  meal	  programs	   37	   49	  	  Friends	   37	   49	  	  Not-­‐for-­‐profit	  grocery	  store	   24	   31	  	  Garden	   19	   26	  	  Low	  cost	  meal	  programs	   17	   22	  	  Community	  kitchen	  programs	   10	   14	  Note:	  Total	  n=77.	  Sample	  size	  differed	  between	  variables	  due	  to	  missing	  values.	  Some	  totals	  not	  equal	  to	  100%	  due	  to	  rounding.	  1.	  Participant	  employment	  at	  time	  of	  survey	  	  2.	  Household	  income	  sources,	  participants	  instructed	  to	  indicate	  all	  that	  apply	  	  3.	  Food	  access	  points	  used	  in	  the	  past	  30	  days,	  participants	  instructed	  to	  indicate	  all	  that	  apply.	  	  	    39 3.3.2 Food bank use Food bank use statistics are reported in Table 3-3. The majority of participants were long-term (>5 year) food bank members (54%), and very few had used the food bank for less than one year (5.5%). Based on MMS use data from over the past year, participants accessed the food bank a mean of two times per month, and 55% of participants attended the food bank an average of two or more times per month in the past year.   Table 3-3 Length and frequency of food bank use 	   	  Sample	  characteristics	   	  	   n	   %	  Length	  of	  use1	  (n=74)	   <	  1	  Year	   4	   5	  	  1	  -­‐	  5	  years	   30	   41	  	  	   >	  5	  years	   40	   54	  Frequency	  of	  use2	  (n=67)	   Low	  (<1	  visits/month)	   11	   16	  	  Medium	  (1-­‐2	  visits/month)	   19	   28	  	  	   High	  (>2	  visits/month)	   37	   55	  Note:	  Total	  n=77.	  Sample	  size	  differed	  between	  variables	  due	  to	  missing	  MMS	  data.	  Some	  totals	  not	  equal	  to	  100%	  due	  to	  rounding	  1.	  Calculated	  from	  participants'	  first	  recorded	  visit	  in	  the	  GVFB	  MMS	  database	  2.	  Calculated	  from	  participants'	  average	  monthly	  visits	  over	  the	  past	  year	  as	  recorded	  in	  the	  MMS	  database	  	  When analyzing usage data, for length and frequency of use there were members with missing and incomplete MMS usage data. This included: a) There was no membership number available that linked to the participant, resulting in no MMS data available (n=3); and b) the MMS did not affirm that the participant had used the food bank over the course of the study (July – Sept 2015) (n=7). For analyses with MMS data, a total of 74 participants were included for length or use, and 67 participants were included for frequency of use. However, due to the survey questions that asked for self-reported a) length of food bank use, and b) number of visits to the food bank over the past quarter, participants with missing MMS data were able to be included for some sensitivity analyses by imputing missing data with self reported values (Appendix E).    40 3.3.3 Household food insecurity and hunger When analyzing the HFSSM, checks were put in place to ensure appropriate module completion. These checks resulted in an analytic size of 74 for all HFI related analyses, as three surveys were removed for incomplete scores; two participants did not complete the modules and one participant chose to end the survey during this module. Table 3-4 describes the prevalence of HFI across the sample. HFI was highly prevalent, with all but two reporting some level of food insecurity in their household. Sixty-six percent of participants were categorized as being severely food insecure, 30% were moderately food insecure, and 1% were marginally food insecure. Most participants (55%) reported no change in hunger since first using the food bank; about a third reported reduced hunger, and 9% reported an increase. Sixty-two percent reported that food bank provisions were not enough to meet their household need.  Table 3-4 Experiences with household food insecurity and hunger  	  Sample	  characteristics	   	  	   n	   %	  Household	  food	  insecurity1	  (n=74)	   Food	  secure	   2	   3	  	  Marginal	  food	  insecurity	   1	   1	  	  Moderate	  food	  insecurity	   22	   30	  	  	   Severe	  food	  insecurity	   49	   66	  Change	  in	  hunger2	  (n=77)	   Decreased	   28	   36	  	  Stayed	  about	  the	  same	   42	   55	  	  Increased	   7	   9	  Adequacy	  of	  food	  provisions	  (n=77)	   Yes	   23	   30	  	   Sometimes	   6	   8	  	   No	   48	   62	  Note:	  Total	  n=77.	  Sample	  size	  differed	  between	  variables	  due	  to	  missing	  values.	  Some	  totals	  not	  equal	  to	  100%	  due	  to	  rounding	  1.	  Household	  food	  insecurity	  category	  calculated	  using	  PROOF	  cut	  off	  values	  for	  the	  HFSSM.	  	  Food	  secure	  =	  0	  affirmative	  responses;	  Marginal	  Food	  Insecurity	  =	  1	  affirmative	  response;	  Moderate	  Food	  Insecurity	  =	  2-­‐5	  affirmative	  responses;	  Severe	  Food	  Insecurity	  =	  6-­‐10	  2.	  Participant	  reported	  change	  in	  hunger	  since	  first	  using	  the	  food	  bank	  	   3.3.4 Associations between household food insecurity and sample characteristics  Table 3-5 presents results for Fisher’s exact tests used to examine the associations between severe HFI and participant characteristics. These include socio-demographic characteristics (gender, age, family size, household structure, education, employment, sources of household income, monthly household income, monthly housing/rent costs) and food bank use   41 categories (length and frequency). Only two sample characteristics were found to be significantly associated with severe HFI: household incomes <$1800/month (p=0.04), and monthly housing/rent costs of >$500 (p=0.01). When alternative categorizations of income (i.e. <$1200/>=$1200) were tested with severe HFI, the significance diminished (Appendix F1). Those who reported both lower incomes (<$1800) and higher housing costs (>$500) also had significantly higher prevalence of severe HFI (p = <0.01) (Appendix F2).  No associations were found between severe HFI and length or frequency of food bank use. This includes when missing values for length and frequency of use were imputed from survey results (Appendix E). No significant associations were found between severe HFI and reported change in hunger, or reported adequacy of food provision (Appendix F3).  Reported change in hunger and adequacy of food provision were also not associated with length or frequency of food bank use (Appendix F4 & F5).  3.3.5 Food bank organizational records We were able to determine through food bank organizational records that the sample did closely reflect the prevalence of single-person households and gender from the wider food bank member population accessing these three food bank sites over the study time period. However, it did not as effectively recruit larger family sizes (≥4 people). Usage records additionally revealed that our sample was not representative of food bank members’ length or frequency of use patterns. We had higher prevalence of long-term (>5 year) members, and a lower prevalence of short term (<1 year) members take part in the study, and a higher prevalence of high-frequency users (>2 times per month) than the sampling frame. All comparisons between our sample and the larger GVFB population are outlined in Appendix G.         42 Table 3-5 Associations between severe HFI and food bank member characteristics Sample	  characteristics	   Severe	  HFI	  	  	  	   	  Fisher's	  exact	  	  	   	  	   No	   Yes	   Total	  	  Gender	  	   	   	   	  	  Male	   15	  (34%)	   29	  (66%)	   44	  (59%)	  	  	  Female	   10	  (33%)	   20	  (67%)	   30	  (41%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  1.00	  Age	  range	  	   	   	   	  	  18	  -­‐	  64	   20	  (32%)	   42	  (68%)	   62	  (84%)	  	  	  ≥	  65	   5	  (42%)	   7	  (58%)	   12	  (16%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.53	  Household	  size	  	   	   	   	  	  1	   14	  (33%)	   29	  (67%)	   43	  (58%)	  	  	  2	   6	  (40%)	   9	  (60%)	   15	  (20%)	  	  	  ≥	  3	   5	  (31%)	   11	  (69%)	   16	  (22%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.89	  Household	  structure	  	   	   	   	  	  Adult-­‐only	   23	  (35%)	   43	  (65%)	   66	  (89%)	  	  	  Children	   2	  (25%)	   6	  (75%)	   8	  (11%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.71	  Education	  	   	   	   	  	  <	  Secondary	  school	   13	  (43%)	   17	  (57%)	   30	  (41%)	  	  	  Secondary	  school	  	   7	  (23%)	   24	  (77%)	   31	  (42%)	  	  	  Completed	  post	  secondary	   5	  (38%)	   8	  (62%)	   13	  (18%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.20	  Employment1	  	   	   	   	  	  Yes	   3	  (20%)	   12	  (80%)	   15	  (20%)	  	  	  No	   22	  (37%)	   37	  (63%)	   59	  (80%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.24	  Wages2	  	  	  	   	   	   	  	  Yes	   7	  (32%)	   15	  (68%)	   22	  (30%)	  	  	  No	   18	  (35%)	   34	  (65%)	   52	  (70%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  1.00	  Social	  assistance3	  	   	   	   	  	  Yes	   21	  (34%)	   41	  (66%)	   62	  (84%)	  	  	  No	   4	  (33%)	   8	  (66%)	   12	  (16%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  1.00	  Disability	  benefits4	  	   	   	   	  	  Yes	   17	  (39%)	   27	  (61%)	   44	  (59%)	  	  	  No	   7	  (24%)	   22	  (76%)	   29	  (41%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.12	    43 Table 3-5 Continued	   	   	   	   	  Sample	  characteristics	   Severe	  HFI	  	   	   	  	   Fisher's	  Exact	  	  	  	   	  	   No	   Yes	   Total	  	  Government	  pensions5	  (CPP/	  OAS/GIS)	  	   	   	  	  Yes	   7	  (39%)	   11	  (61%)	   18	  (24%)	  	  	  No	   18	  (32%)	   38	  (68%)	   56	  (76%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.78	  	  	  Household	  income,	  monthly	  	   	   	   	  	  $0-­‐1799	   20	  (30%)	   46	  (70%)	   66	  (90%)	  	  	  ≥$1800	   5	  (71%)	   2	  (29%)	   7	  (10%)	  	  	  	   TOTAL	   25	   48	   73	   p	  =	  0.04*	  Home	  ownership	   	   	   	   	  	  	  	  	  	  	  	  Yes	   1	  (33%)	   2	  (67%)	   3	  (4%)	   	  	  	  	  	  	  	  	  No	   24	  (33%)	   47	  (67%)	   71	  (96%)	   	  	  	  	  	  	  	  	  TOTAL	   25	   74	   74	   p	  =	  1.00	  	  Housing	  costs,	  monthly	  	   	   	   	  	  $0-­‐500	   19	  (48%)	   21	  (53%)	   40	  (54%)	  	  	  >$500	   6	  (18%)	   28	  (82%)	   34	  (46%)	  	  	  	   TOTAL	   25	   49	   74	   p	  =	  0.01*	  Length	  of	  use	  	   	   	   	  	  <	  1	  Year	   0	  (0%)	   4	  (100%)	   4	  (6%)	  	  	  	  1-­‐5	  years	   12	  (41%)	   17	  (59%)	   29	  (41%)	  	  	  >5	  years	   12	  (32%)	   26	  (68%)	   38	  (54%)	  	  	  	   TOTAL	   24	   47	   71	   p	  =	  0.30	  	  Frequency	  of	  use6	  (past	  year)	  	   	   	   	  	  Low	  (<1	  visits/month)	   3	  (30%)	   7	  (70%)	   10	  (15%)	  	  	  Medium	  (1-­‐2	  visits/month)	   6	  (32%)	   13	  (68%)	   19	  (29%)	  	  	  High	  (>2	  visits/month)	   13	  (36%)	   23	  (64%)	   36	  (54%)	  	  	  	   TOTAL	   22	   43	   65	   p	  =	  0.94	  Note:	  Total	  n=77.	  Sample	  size	  differed	  between	  variables	  due	  to	  missing	  values.	  Some	  totals	  not	  equal	  to	  100%	  due	  to	  rounding.	  *	  p	  =	  <0.05	  1.	  Participant	  employment	  at	  time	  of	  survey	  2.	  Wages	  received	  by	  any	  household	  member	  	  3.	  Social	  assistance	  (welfare	  and/or	  disability	  assistance)	  received	  by	  any	  household	  member	  	  4.	  Disability	  benefits	  received	  by	  any	  household	  member	  5.	  Government	  pension	  received	  by	  any	  household	  member	  6.	  Average	  monthly	  visits	  over	  the	  past	  year	   3.4 Discussion 3.4.1 Demographic characteristics These findings describe a high prevalence of poverty, unemployment, and receipt of government based income support amongst Vancouver food bank members, consistent with   44 other reports of food bank members’ socio-economic status (20,21,25). Only 9% of households had monthly incomes above $1800, which approximates the low income cut-off ($20,160/year) for single adults living in Vancouver (104). As incomes below this cut-off represents economic vulnerability (109), this indicates that 91% of participants were living on incomes that could be considered below the poverty line. Furthermore, only participants in household sizes of two or more people reported incomes above $1800, suggesting that a potentially higher prevalence of the sample were living below the poverty line for their household size. The exact prevalence of participants living under the poverty line for their household size was unable to be determined due to the fact that income was collected in range categories that did not align with low-income cut-offs for household sizes above one. Therefore, 91% can be considered a conservative estimate. Although many of the participants could be considered working age, only 19% reported being employed, and most households received social assistance benefits as a source of income. An overwhelming number were currently receiving disability benefits, in a far higher proportion than the 19% of households reported in a recent national survey on food bank participation (20). This point is especially troubling given the fact that receipt of disability benefits in Canada is due to recognized reliance on the state to assist in meeting basic needs due to impediments to maintaining steady employment (110,111). Although disability benefits do provide more funds than basic income assistance/welfare (112), these social assistance rates have been continually documented as being inadequate to ensure adequate financial access to basic living costs, including food (1,20,44,45,47). A recent study from Canada has found that increasing income assistance rates can have a direct impact on prevalence of household food insecurity. Low-income seniors over age 65 have been found to experience lower probability of food insecurity than younger (55-64 year old) low-income groups (113). This is thought to be associated with the protective effects that come from the guaranteed income benefit they receive, which provides a higher rate of social assistance than that received before age 65 (113). This suggests that improving social assistance rates could have beneficial results in reducing food insecurity amongst those who are unemployed or no longer able to work.  Lone female parents had the highest prevalence of total and severe HFI in Canada when last reported in 2012 in the CCHS (1). Although households with children make up 18.4% of food insecure households in BC (99) and data from Food Banks Canada has found that approximately 35.8% of households assisted by BC food banks were families with children (20),   45 these populations were not well represented in our sample. There are multiple potential reasons for this, including that this study may not have effectively recruited families with children due to challenges of participating in the survey while caring for children. However, these findings could also reveal food banks as a less accessible environment for those with children. A recent study found that only 23% of a sample of low-income families with children in Toronto reported to use food banks and issues related to scheduling and unsuitable food were described by the families who chose not to use them (28). These indicate the potential of increased inconvenience for parents to attend specific locations during the limited food pick-up time frames, and the difficulty of households’ meeting children’s needs and preferences amongst the offerings at the food bank. Furthermore, the format for accessing food at the food bank, including the stressful environments (revealed in the mixed methods study in the next chapter), may be less comfortable for parents to navigate with children.  Single-person households represented 28.3% of BC households in the 2011 census (114), but they make up the largest proportion (42.9%) of food insecure households in BC (99). This group represented 58% of our study sample, and coincides with nationally collected data from 2015 which reported that the prevalence of single-person households accessing food banks has grown since 2001, with the provincial prevalence in BC at 53.6% (20). These findings are in contrast to a recent analysis of a BC food bank organization’s meeting minutes, promotional documents, and correspondence, that found that food bank members tended to be generalized in promotional materials to the public using the term ‘family’(56). In this analysis, Carson argued that the framing of these statements are based on the assumption that food insecure families, and especially children, are more deserving of charitable donations than other groups (56). In light of available evidence, is not inclusive of the majority of this food bank member sample. The vulnerability of single-individual households in BC is highlighted by their relatively high prevalence of food insecurity, which at 15.6%, was second only to female lone parent households (1). Furthermore, income assistance rates for single adults under 65 have remained flat since 2008 (115). In the face of inadequate income assistance rates, and less access to financial assistance and tax benefits brought from other household members (including partnerships and children), this leaves single individuals particularly vulnerable to inadequate financial resources and food insecurity (47).    46 3.4.2 Food bank use Food banks were established to respond to emergency need, but have been noted in other studies to be utilised as a long-term food resource for many of their clients (17,21,22). Length of food bank use previously reported in Canada includes a study of Ontario families that determined that median length of time families had used the food bank was 2.2 years, with only 28% using the food bank for less than one year (24) . Our study found that there was a relative absence of members who had used the food bank for less than a year, and that the majority of this sample of food bank members had been using services for greater than five years. Our study also found that 55% of this sample accessed food bank services more than two times every month, which described a higher prevalence of frequent use than other studies. A 1998 study from Quebec determined that 37% of a randomly selected sample of 490 food bank members utilised the food bank two or more times per month (23), and another study of families from Toronto determined that food assistance was obtained an average of 1.3 times each month (24). Our study recruited a non-generalizable convenience sample of participants, and food bank programs may have different restrictions on the number of times that clients can access their services (17) making these visit frequencies difficult to compare. However, results are concerning as they reveal a frequency of use that could be described as ‘regular’ for some participants, indicating that food banks may be used as an ongoing resource for some individuals. This adds evidence to the critique of the term ‘emergency assistance’ to frame the services that food banks provide (23,116), as it is not reflective of the experience of individuals who use it the most.   3.4.3 Resources used to obtain food In addition to using the food bank, members were accessing multiple resources to assist in meeting their food needs.  The most prevalent of these included free meal programs, friends, and not-for-profit grocery stores. Other studies from the US have determined that food bank clients were turning to multiple forms of food programs to obtain food (21,59), expending sizeable amounts of effort in order to increase their food access. These findings suggest that food bank provisions are not adequate to meet some households’ food needs, as they were only one avenue used by food insecure households to obtain food. Furthermore, the relatively low prevalence of participation in community gardens and community kitchens reflect that these programs may not be broadly available, that there may be barriers to accessing these programs,   47 or that vulnerable groups may believe or find that these types of programs are not as relevant or able to meet their needs. As these programs are often seen as measures that assist communities to move towards greater food security (85) determining why food bank participants are not utilising these programs could build understanding of how these programs can be made more accessible or applicable for these populations.    3.4.4 Household food insecurity Consistent with other Canadian studies, severe HFI amongst our sample was highly prevalent. In Toronto, 26.8% of a sample of families using food banks in 1998 were reported as being severely food insecure (24), and in 2010 in BC 68.6% of a sample of food bank members were classified as severely food insecure (63). Notably, the prevalence of severe HFI from the BC study (63) was roughly equal to the current findings. This high prevalence of severe HFI amongst food bank members is in-line with work published by Loopstra et al, reporting that severely food insecure low-income families with children had higher odds of using the food bank than their food secure counterparts (28). Though studies have not looked specifically at other groups, such as single-person households, one would assume this association would remain.  No demographic characteristics in this study were associated with severe HFI, but this high level of vulnerability was associated with two socio-economic indicators: household income, and housing costs. These findings come as no surprise, as HFI has been well reported to be associated with lower income in Canada (1,6,7). However, only when incomes were dichotomized to those below or above an approximation of the low-income cut off (104) were significant associations with severe HFI found, and not when alternate categorizations of income were used (Appendix F1). This may be reflective of the exceedingly low incomes that most participants reported, and the limited ability of incomes below the low-income cut off range to protect against severe HFI.  This study found no significant difference in prevalence of severe HFI status across different length or frequency of use patterns, indicating that longer term and regular food bank use over the previous year does not appear to be associated with lower or higher prevalence of severe HFI. Similar results were found in a 1999 study from Toronto, where the frequency of food bank use of families with children was not correlated with HFI status (24). These findings suggest that food banks do not appear to buffer the experiences of severe HFI for many of the   48 members who use them, even those who are using them in the most frequent manner. As the HFSSM poses questions in relation to financial access, one could argue that assistance through charitable sources will not be reflected on a participant’s categorization of food insecurity using this tool. However, results from participants subjectively reporting their change in hunger since using the food bank determined that the majority of participants described no change in their hunger. Furthermore, the majority of our sample reported that food bank provisions were not enough to meet their household needs. These findings corroborate with other studies of food bank organizations, which have noted that management and staff readily acknowledge the food provided is not adequate to meet member need (17,27), and offer further suggestion that food banks are not sufficiently addressing members’ food insecurity.   3.4.5 Strengths and limitations  Strengths of our data collection included a rich set of survey questions developed using a CBPR approach with the input and feedback from a variety of key stakeholders. The interviewer-administered survey format also resulted in a low level of non-response to survey questions amongst participants. However, limitations of this study include the small non-random sampling method that constrains the generalizability of our findings, as this sample may not be representative of all food bank members in Vancouver or elsewhere. We were able to determine through food bank organizational records that the sample did closely reflect the gender divide and prevalence of single-person households of the larger GVFB member population. However, the recruitment method did not as effectively recruit larger family sizes. We also had a lower prevalence of short term (<1 year) and low-frequency (<1 visit/month) users than organizational records indicated for the wider sampling frame. This may have been due to long-term members being more comfortable participating in the survey, or greater familiarity being developed with higher-frequency users over the course of the recruitment period. Future studies should look to improve the method of participant selection to reflect the experiences of different member groups and improve generalizability. This could be achieved through the use of random sampling of food bank members through the MMS database, which may result in increased recruitment of less frequent users and new members. Administering surveys in multiple languages, as well as ensuring that the research is accessible to families with children, will also improve inclusivity and may improve generalizability.    49 Although findings suggest that food bank use does not ameliorate severe HFI for this subsample of food bank members, this study did not collect repeated measures of HFI and cannot make any claims regarding the directionality or effectiveness of food bank use in reducing severity of food insecurity over time. Longitudinal evaluation of food bank usage patterns on HFI outcomes remains warranted. Additionally, this study relied solely on quantitative data, and does not describe why food bank members elect to access food banks over the long-term or how food banks may buffer subjective experiences of hunger and food insecurity.    3.5 Conclusions This study provides quantitative results from the exploratory phase of a community-based research partnership with a food bank organization. The results contribute to the understanding of the socio-demographic characteristics and experiences of food bank members in Vancouver. In contrast to the fact that most Canadian research on food bank use has focused on families with children, our findings are consistent with national reports that lone individual households are the most prevalent demographic amongst food bank members. They remain an important demographic to target for future studies on food bank use. Although not representative of all food bank members, our findings found extreme economic vulnerability and high prevalence of long-term regular reliance on food banks in this sample. Reports of unmet need and high prevalence of severe HFI amongst members adds further weight to the argument that food banks are not a sufficient response to address HFI. Future public policy and research efforts should focus on poverty reduction and affordable housing, as they appear to be priority areas to reduce severe HFI amongst food bank members.     50 Chapter 4: “Nothing is going to change three months from now.” Insights from a mixed methods characterization of food bank use in Greater Vancouver  4.1 Introduction  Household food insecurity (HFI), characterized by limited financial access to sufficient, safe, and nutritious foods, is a rising concern in Canada where approximately 1.7 million (13%) of national households were food insecure in 2012 (1). During the 1980s and 1990s food insecurity emerged as a serious concern across North America, due to the economic recession in the early half of the 1980s and a subsequent neo-liberal shift resulting in reduced government funding for social programs (15,17,55,56). While food insecurity and ad-hoc charitable food assistance have long existed, increasing hunger and the absence of an effective governmental response has resulted in charitable agencies taking on a greater role in providing food to citizens in need across North America (15,17,19,59). Food bank programs feature most prominently in this charitable response by collecting food donations from the private sector and food industry and redistributing food items to community agencies or directly to individuals. Initially believed to be a temporary solution to hunger brought on by the recession of the 1980’s, food banks now have a strong presence in the North American food system and mainstream discourse around the response to hunger (15). Food banks were originally envisioned as an emergency measure, thought to assist individuals during short-term changes in financial situation (15). Yet, research from North America suggests that food banks are being used by some participants as a long-term subsistence strategy (21–24). Some researchers have speculated that long-term unemployment was a contributing factor to ongoing use (21,23), and studies from the US and Canada have found high proportions of food banks users reporting to participate in government income support programs, suggesting that food banks are used as a supplemental measure to manage inadequate income support levels (20,21,23,68). However, none of these studies have verified with participants if and why they view the food bank as a long-term resource, suggesting a need for a participant-framed understanding of the underlying issues that result in long-term use.    51 Although food banks have gained wide public and corporate support (15), several key critiques of the charitable food-based approach question the ability of food banks to contribute to sustained reductions in food insecurity. Firstly, assistance through food banks is reliant on donations, which limits capacity to be selective about food quality or offer standardized amounts of food (17,19,27). Studies have found food bank organizations restrict the amount of food they provide when the number of individuals requiring their services rise or their donations fall (17,27), and that 72% of administrators believed their users required more food than they could provide (17). Secondly, long-standing criticisms of the food bank system have raised concerns about food charity as an approach to food insecurity (55). Though they are not designed or mandated to meet household food needs, their presence creates the impression that something is being done in response to hunger (15,55,56). By decreasing social pressure to fix the underlying financial root of food insecurity, food banks may inadvertently be depoliticizing government roles in addressing it (15,29,55,56).  Given these issues, some food bank organizations have begun adjusting their service models to address the previously reported deficiencies and concerns, by providing additional supports and organizational focus to assist their members in managing the broad range of life challenges and situations that underlie food insecurity (19,30,48). The aim of these emerging approaches can be outlined using the community food security continuum framework (84,85). This framework describes the progression of food banks from working solely in an “efficiency stage”, where the focus is to provide immediate temporary relief from hunger, to a secondary “transition stage” where community capacity building takes place through participatory program development. The overall trajectory of this framework is towards eventual food systems redesign, where incremental changes occur in community responses to food insecurity until capacity, advocacy and policy efforts are set to support food security at broader government and social scales.  In order to create successful, sustainable solutions to food security issues, participatory approaches that include the affected groups’ perceptions and solutions are warranted, as they provide greater agency throughout the process and are better attuned to meet the groups’ needs (88). Understanding how food bank members perceive their major challenges and reasons for food bank use, and whether they view the food bank as a short or long-term resource for attaining food security, can provide further clarity to why and how the food bank is being used   52 by the food insecure community. Furthermore, understanding food bank members’ experiences with food bank services will provide valuable user-developed insight into areas where organizations can focus future support efforts across the community food security continuum.   The objectives of this study were to conduct participatory research with a local food bank organization: 1) to determine to what extent food bank members view the food bank as a short or long-term food augmentation strategy and explore self-perceived challenges in relation to achieving long-term food security; and, 2) to explore food bank members’ current experiences with accessing food banks as part of their food security strategy, and how they envision the food bank adjusting to better meet their needs. Mixed methods approaches are not readily used with food bank populations, but by combining the strengths of both quantitative and qualitative methods, this approach can integrate and draw interpretations to develop a better understanding of members’ experiences (92,97). Therefore, this study used two forms of data collection approaches to provide insight into the experiences and challenges food bank members face to achieving long-term food security, and explore participant envisioned ideas for change to food bank services.    4.2 Methods Recognizing a lack of an evidence base on food bank transformations and program change, this research was initiated by our food bank partner and a community based participatory research (CBPR) orientation was used to frame our work. A CBPR orientation encourages participation of community members and researchers in all aspects of the research process in order to promote community driven selection of issues (89,91). This resulted in close collaboration in all stages of the research process between the university research team, food bank organization, and food bank members.  The research team met with staff members and key informants from the food bank to determine areas of interest that would help address the organization’s major knowledge gaps for service provision. The organization’s vision is to provide assistance that better meets their members’ needs, and offers additional services to support their members towards greater food security (87). They reported a shortage of data regarding who were accessing their programs, and wanted to understand food bank members’ perceived experiences with their services. To extend   53 the CBPR orientation to the community of food bank members, an additional aim of this initial study was to ensure we were “starting where the people are” (89,117) and that the approach to future program updates and research efforts were inclusive and relevant to their needs and wishes. Public health concerns related to eliminating health disparities, such as food insecurity, have been argued to be best addressed in an approach to research that is framed from an emancipatory perspective – that is fostering democratic participation of affected community members (89). Our methods and research focus were designed to create space for food bank members to identify their own issues, describe the strengths and challenges within their community, and take the lead in imagining changes that will help them realize their own self-identified goals (88,89).  A mixed methods design was seen as an appropriate approach to achieve the goals of the food bank organization and align with CBPR orientation. Qualitative data can better feature the voices of marginalized viewpoints by providing opportunity for participants to frame and offer depth to their experiences, and quantitative data provides more context into the characteristics and opinions of the wider food bank community (89,92). Offering multiple avenues for food bank members to participate also created the opportunity for members to contribute in the way that was deemed most comfortable to them. Therefore, a convergent mixed methods design was used, where qualitative and quantitative data pertaining to research questions were collected in parallel, analysed separately, and then compared for interpretation, to determine how views expressed by participants were representative of trends across a larger sample of food bank members (92) (see figure 4-2). Both forms of data collection occurred between July and September 2015, and ethical approval for this project was obtained from the University of British Columbia Human Ethics Review Board (H15-00118).    54  Figure 4-1 Concurrent convergent mixed methods design  4.2.1 Participant recruitment Participants were active food bank members recruited from an organization that provides food bank services to thirteen sites across ten neighbourhoods within the GVRD. Five sites were selected to participate in the study. These five sites were selected based upon discussions with our food bank community partner, and reflected sites that had strong volunteer support and adequate size to accommodate the research activities. Focus group participants were recruited at all five sites, however, only three of the sites were sampled for survey participation due to the preferences of our community partner.  For survey recruitment, three sites were selected from three different neighbourhoods aiming to showcase a range experiences from across the GVRD. Survey recruitment occurred over a seven week period at these sites, as outlined in chapter three. A convenience sample of food bank members was recruited by setting up a research booth once per week during food bank operating hours and inviting members to participate in the study as they waited in line at the food bank.  Focus group participants were recruited from five food bank sites, including the three survey sites and two additional sites, which were selected to provide a greater breadth of insight   55 into the food bank experience by drawing data from an additional neighbourhood (see Appendix A). Focus group recruitment occurred over a single recruitment day at each of the sites. Members were able to self-select for participation by signing up at the research booth, but were additionally purposively recruited while waiting in line by a research team member. This purposive recruitment was based on recognizable traits (age, gender) and was done in order to promote heterogeneity and gain insight into the diversity of experiences amongst the member population (93). The research team collected contact information, demographic data, and scheduling availability for individuals interested in participating in the focus group via sign-up sheets. After the recruitment session, the focus group moderator assessed the available time slots to find the time that suited the most demographically varied group of participants. The focus group moderator then called each participant back to confirm their interest in participating and provided them with the chosen time and location. Exclusion criteria for participation included members who were under the age of eighteen, had limited ability to communicate in English, or had impaired mental capacity where informed consent was unable to be obtained. Members were able to participate in both the survey and focus groups if they wished, though no participants did. Participants of both the survey and focus groups were offered a $5 honorarium or two bus tickets valued at $5.50.  4.2.2 Data collection methods    4.2.2.1 Qualitative  Data was collected through guided focus group discussions, designed to foster dynamic participant interactions that stimulate thinking and verbal contributions (93), and to examine research questions from the perspective of the participants (92,100). Focus group sessions were held in community centres or libraries near food bank sites, and were scheduled in the week following recruitment. Two research staff members facilitated each focus group, one PhD student with a background in qualitative research acted as the focus group moderator for all five sessions, and a secondary staff member assisted with note-taking and audiovisual set-up. A circular style of seating was used to facilitate conversation and spontaneous responses and interchange (100). Each focus group session lasted between 75-90 minutes, and were video and audio recorded. Consistent with the Behavioural Research Ethics Board guidelines, every   56 member was informed that the discussion would be recorded, and that their contributions would be transcribed and analyzed for the purposes of this study. An interview script was devised collaboratively with the food bank organization to address study objectives. Focus group questions were constructed to develop dialogue around participants’ perceived future need of food bank services and the constraints they face that limit their food security. To better understand how participants saw the food bank’s role in the community food security continuum, questions were also posed to encourage members to describe their current experiences at the food bank and how they envision the food bank transforming to better meet their needs. Table 4-1 outlines the questions posed in the focus group.  The focus groups followed a semi-structured format, whereby the moderator posed the list of questions to the group to ensure components of each focus group’s dialogue aligned to the research questions. The moderator generally followed the same order for each session, though adjusted the order of questions to follow the flow of participant discussion if required. Nondirective responses were used to encourage the respondents to answer more fully, and ensure that there was no misinterpretation if the original response was unclear (93). The moderator additionally provided probes and questions to align the group more closely to the question originally posed when needed.   4.2.2.2 Quantitative  Quantitative data were collected through a cross-sectional survey, and focused on socio-demographic and socio-economic characteristics of food bank members, and their experiences and ratings of food bank services. Questions sought to learn about participants’ household size and structure, income range, income sources, housing status, health status, food preparation capacity, projected future food bank use, experiences related to safety and respect at food bank sites, and experiences and preferences in regards to food provisions. A literature review was conducted of previous survey tools that assessed these constructs. Survey questions were developed using validated Canadian questionnaires wherever possible (101,102), as well as adapted from previous Canadian and US studies that recruited individuals who used food banks (68,82). When no previously used questions or tools of appropriate length could be found to   57 assess the constructs of interest, the research team devised additional questions. All questions were assessed by content experts on the research team (n=6), and were piloted with Food Bank staff (n=14), and food bank members (n= 5) to ensure appropriateness of question selection and wording for the population of interest. A summary of survey questions pertaining to each research objective is outlined in table 4-1, with complete questions available in Appendix B.  The cross-sectional survey was administered by trained interviewers to ensure that English-reading level of participants would not affect survey results, and to promote higher completion rates (100). Interviews were conducted face-to-face on-site or over the telephone using iPad tablets, and took approximately 45 minutes to complete. On-site interviews were held in a private room or an enclosed research tent that offered privacy for participants. Telephone interviews were conducted with participants who stated a preference to complete the survey from their home. Research team members followed the same survey format for both on-site and telephone interviews.   Table 4-1 Focus group and survey questions Topic Focus Group Questions Survey Questions Projected ongoing food bank use Do you think you will still be coming to the food bank 3 months from now?   What are the main reasons you continue to use the food bank?  What are your biggest challenges? Do you think that you will be coming to the food bank 3 months from today?  Socio-economic questions: income range, income source, housing costs, education level; Health status. Current experiences and challenges with the food bank Since coming to the food bank, how has your life changed?  What do you find most challenging about using the food bank? Likert scale response (1-5) related to experiences at the food bank: positive experience, physical safety, respected by volunteers, respected by other members;  Adequacy of quantity of food obtained;  Dietary restrictions. Preferences and vision for the future What kinds of foods would you like to see at the food bank, and why?  How can the food bank improve its services for you personally?  If you were in charge, how would you run the food bank? What would you do differently?  What resources do you need to be able to feed yourself?  How can the food bank help you to achieve your dreams?  Food preferences;  Access to food preparation appliances;  Self-rated cooking skill; Interest in other community services being offered at the food bank?  Skills or knowledge to share with others?     58 4.3 Analysis 4.3.1 Qualitative data analysis  Research staff transcribed each focus group discussion verbatim, and one member of the project team analysed the transcripts using thematic analysis (93). A first pass of the transcripts was conducted to gain familiarity with the subject matter. The transcripts were then coded using an open coding process, highlighting content relevant to the pre-determined research objectives. The transcripts were then given a third pass using line-by-line analysis to further categorize content into codes and sub-level codes according to similar ideas in participant narratives. Coding was iterative, and aimed to establish, add, and revise codes that developed from all five focus group transcripts. After the coding scheme had passed through multiple iterations, axial coding was then used to identify relationships between codes, which were then organized into common themes reflected throughout the data. Each theme was defined, and enumeration was determined for each theme discussed at both the focus group and participant level. Qualitative data were analysed using Nvivo™ qualitative data software (QSY International Pty Ltd. Version 10.2.1).   A single author coded all transcripts, and efforts were conducted to maintain consistency throughout the analysis process. This included maintaining an audit trail of all transcripts, memos, and coding frameworks. Reflexivity was enhanced via a peer-review conducted with a senior researcher with qualitative methods expertise, to outline the analysis process and suggest different ways of organizing the data to identify new insights. Additionally, participants were contacted to inform them of the study findings and request their feedback and critiques as a method of member checking to confirm validity of our findings.   4.3.2 Quantitative data analysis Descriptive statistics explored the distribution of variables across the sample, and were visually examined using bar charts. Some questions throughout the survey requested participants to specify their response using an open-ended response option (health status & dietary restrictions). These answers were analyzed qualitatively, coding responses into themes determined on a question-by-question basis, and enumerated into categories. All data were managed and analysed using STATA™ (StataCorp LP. Version 12.0, 2011).    59 4.3.3 Mixed methods analysis A side-by-side comparison of qualitative and quantitative findings was conducted to identify how quantitative data supported, converged and/or further illuminated the qualitative findings (92).   4.4 Results 4.4.1 Participant characteristics Five focus groups were conducted with 27 participants and a total of 77 participants completed survey interviews. Participant characteristics of both groups are outlined in Table 4-2. Participants were evenly split amongst gender, and the majority represented lone-individual households, and adult-only households.     60 Table 4-2 Food bank member sample characteristics, survey and focus groups Sample characteristics     Survey Focus groups          n (%)   n (%) Gender  Male 45 (59) 12 (46)   Female 31 (41) 14 (54) Age  < 65 64 (84) 18 (67)   ≥ 65 12 (16) 9 (33) Household size 1 45 (58) 15 (65)  2 15 (20) 7 (30)   ≥ 3 17 (22) 1 (4) Household structure Adult Only 69 (90) 21 (88)  2 Adult households w/ children <18 6 (8) 1 (4)   Single parent households 2 (3) 2 (8) Employment Yes 15 (19)    No 62 (81)   Household income source1  Social assistance - all but pensions 65 (84)   Disability assistance 47 (61)   Wages 22 (29)   Government pension 19 (25)  Household income, monthly $0 - 599 9 (12)    $600 - 1199 43 (56)   $1200 - 1799 17 (22)    ≥ $1800 7 (9)   Housing costs, monthly $0-500 42 (55)    >$500 35 (45)   Health issue(s)2 Any health issue 59 (77)   Hypertension 22 (29)   Chronic pain 14 (19)   Mental health concern 12 (16)    Diabetes 10 (13)   Dietary restriction(s)2 Yes 37 (48)   Dental related restrictions 11 (14)   Allergies 9 (12)    Health or disease related 8 (10)   Note: Total survey n=77. Total focus group n = 27.    Sample size differed between variables due to missing values. Some totals unequal due to rounding.  1. Household income sources, participants instructed to indicate all sources 2. Participants instructed to indicate all that apply      61 4.4.2 Qualitative results  Themes, subthemes, and enumeration of their presence across discussions at both the focus group and participant level are noted in tables 4-3 and 4-4.  Table 4-3 Thematic coding and prevalence of themes for projected food bank use  Theme Subthemes  Focus groups1 (n = 5) Participants2  (n = 27) Food bank as a long-term strategy 5 17  Financial constraints 5 21     Inadequate income 5 17     Inadequate social assistance rates 5 11     Housing costs 5 11     Unemployment 5 7     Rising food prices 3 8     Transportation costs 4 6     Child care costs 1 1  Health challenges 5 13     Disability 5 11     Chronic disease related 4 6     Mental health related 3 7     Aging related 2 2 Food bank as a temporary measure 1 1     Future employment 1 1 1. Prevalence of focus groups referencing each theme or subtheme 2. Prevalence of focus group participants referencing each theme of subtheme  Table 4-4 Thematic coding and prevalence of themes for experiences and visions for the future of the food bank system  Theme Subthemes  Focus groups1  (n = 5) Participants2  (n = 27) Food bank as support and stressor       Food bank as a support        Financial benefit 5 10     Gratitude 5 13     Sense of community 3 4  Food bank as a stressor         Loss of dignity 5 13     Stressful situations on-site 4 13          62 Table 4-4 Continued  Theme Subthemes Focus groups1  (n = 5) Participants2  (n = 27) Food provisions        Current food quality         Poor food quality 5 19     Expired/rotten 5 16     Not good 2 5     Unhealthy 2 2     Good food quality 4 10     Healthy options 3 8   Foods past “best before” are ok 3 4     Improved 2 2   Current food quantity         Inadequate amount 5 15     Food allergy related 4 7     Enough food 1 1   Food preferences         Protein rich foods 5 13     Fruit and vegetables 4 9     Dairy and alternatives 4 8     Healthy food items 4 8     Meal combinations 3 7     Work with donators to improve quality 2 4  Additional items         Personal hygiene products 4 7     Bus tickets 1 4     Coupons for grocery stores 1 2 Service delivery      Current distribution system  5 21     Line-up system problematic 5 18     Inequitable distribution  3 6     Limited availability (hours, locations) 2 6     Site too small 2 5  Current environment/member dynamics         Don’t feel safe (aggression) 4 9     Stress and anxiety 2 6   Improving distribution system         Food bank delivery service 3 9     More availability (hours, locations) 3 4   Improving environment to support wellness         Staffing (security guard, training) 5 8     Non-smoking line-up 1 2   63 Table 4-4 Continued   Themes          Subthemes Focus groups1  (n = 5) Participants2  (n = 27) Additional services         Health and wellness support 5 15     Counselling 4 8     Recreation facilities 2 4   Food skills programs  4 11     Community kitchens 3 6     Recipes 3 5     Community gardens 2 6   Access to job and volunteer opportunities 4 6 Desires and goals         Economic change 5 18     Employment 4 13     Improved social assistance rates 4 6     Winning the lottery 2 3   Public policy changes 4 11     Advocacy 2 8   Give back to the community 3 4   Health improvement 3 3 1. Prevalence of focus groups referencing each theme of subtheme 2. Prevalence of focus group participants referencing each theme of subtheme  4.4.3 Mixed method results A side-by-side comparison of qualitative and quantitative findings is available in Table 4-5 and discussed below.   Table 4-5 Side-by-side analysis of qualitative and quantitative data Focus group results (n=27) Survey results (n=77) Projected ongoing food bank use Food bank as long-term strategy    Majority explicitly reported yes (n=17, 63%) 88% responded 'Yes' to future/ongoing use   Economic and financial challenges (n=21, 78%) 91% household incomes below $1800 / month   Health challenges (n=13, 48%) 81% unemployed   84% government social assistance (non-pension)   45% paying rents >$500/month   77% reported health concern Food bank as temporary measure    One participant reported no (n=1, 4%) 0% said no; 12% unsure    64 Table 4-5 Continued Focus group results (n=27) Survey results (n=77) Experiences and envisioning the future of the food bank Food bank as a source of support and distress   Food bank as a support system:  81% agreed positive experiences at food bank Gratitude for service (n=13, 48%)  86% respected by volunteers Financial benefit (n=10, 37%)  Community (n=4, 15%)   Food bank as distress:   Loss of dignity (n=13, 48%) Food provisions    Inadequate quantity (n=15, 56%) 62% inadequate quantity to meet need  Poor quality (n=20, 74%)   Difficult to navigate dietary restrictions (n=7, 26%) 48% dietary restrictions: dental issues, allergies, and disease related  Preferences:   Protein rich foods (n=13, 48%) 73% more meats and alternatives Fruits and vegetables (n=9, 33%)  65% more fruits and vegetables Dairy products (n=8, 30%) 43% more dairy and alternatives  Work with donors to improve quality (n=9, 33%)    Non-food items: personal care products (n=7, 26%), bus tickets (n=4, 15%), and coupons (n=2, 7%) 20% wanted more non-food items: personal care products and cleaning products Service delivery   Line-up distribution system problematic (n=18, 67%) 80% reported feeling safe at the food bank Availability of services limit access (n=6, 22%)  Stressful environment (n=6, 22%)  Aggression from other members (n=9, 33%) 80% respected by other members  Improve staffing (n=8, 30%)   More availability: locations and timeframes (n=4, 15%)   Non-smoking line-up (n=2, 7%)   Additional services 77% want additional services at food bank  Health and wellness support (n=15, 56%) 77% reported health concern  Food and nutrition programming (n=11, 41%) 75% reported excellent or good cooking skills  Food bank delivery service (n=9, 33%)  Desires and goals   Improved financial situation (n= 18, 67%)   Public policy change (n=11, 41%)   Access to job/volunteer opportunities at the food bank (n=6, 22%) 81% unemployed  Give back to their community (n=4, 15%) Improved health (n=3, 11%) 55% skills and knowledge they could share with other members Note: (n=x, %) throughout focus group results reflects prevalence of theme or subtheme at the participant level   65 4.4.3.1 Food banks as a long-term resource Focus group responses were categorized by whether participants did or did not view the food bank as a long-term resource (yes/no). All five focus groups discussed the role of the food bank as long-term resource, and the majority of both focus group and survey participants affirmed that they would continue to use the food bank long term. Indicating recognition of the increasing reliance on food banks, and its function as an ongoing food provision service for many, one member pointed out “I remember when it (the food bank) started, it’s supposed to be a little extra. And now, the food bank has been called upon to feed people. We’re not talking extra here. We’re just talking about general food, day to day.” Financial constraints and health challenges were revealed as two of the major challenges facing food bank members that resulted in the food bank becoming “a part” of their lives as a long-term resource.  Financial constraints, related to financial reasons for ongoing food bank use, were discussed in all five focus groups, and focused on insufficient income in the face of competing financial demands. Participant narratives revealed experiences of low incomes from underemployment or unemployment, or insufficient government social assistant rates to meet their basic needs. Those reliant on disability benefits lamented that ongoing food bank use was a necessity given their limited circumstances, as “nothing is going to change three months from now” and “for fifteen years the cost of living has gone up but the amount of money for disability for my brain injury has stayed the same”. Corroborated by the survey data, monthly household incomes reported on the survey were very low, with 68% living on less than $1200 per month, and 91% reported incomes below $1800 per month, which approximates the 2015 low-income-cut off for a single individual in Vancouver ($20,160/annum)(112). The majority of survey participants were unemployed (81%), and most reported their households were currently receiving social assistance (84%), and specifically disability assistance (61%). Together, these highlight that current social assistance rates are a major constraint for a large proportion of our sample. Some participants also expressed dissatisfaction with current minimum wage levels, and others did not believe that the incomes they could earn in the job market would be able to support them, with one parent revealing that “even if I am working, there is no way I will be able to feed a teenage boy with the income I make.”  Competing financial demands discussed in focus groups were largely related to high housing costs or limited affordable housing, and narratives described tough decisions being made   66 when allocating limited funds. All focus groups touched on the “very expensive” housing in Vancouver, revealing: “The rent takes away your ability to feed yourself, and your ability to live. You can’t have both.” Surveys indicated that 96% of participants did not own their home, and 55% were paying >$500 per month in rent. Other necessities that focus group participants reported having difficulty purchasing included food in the face of “sky rocket” prices in the grocery store, and transportation costs. Lost capacity for employment due to health issues was also revealed throughout all five focus group discussions as a factor resulting in long-term food bank use, and described challenges related to disability, mental health concerns, chronic disease, and aging. As one individual who had experienced an accident explained - “it’s just like financial downspin of not having a job and the disability not being enough to pay for things”. Mental health concerns, related to depression and feeling stressed and “overwhelmed” by their situation were also disclosed in four focus group discussions. Survey data determined the prevalence of health issues amongst food bank participants was high, with 77% of participants reporting one or more health conditions, chief among them being hypertension, diabetes, mental health issues, and pain. The comment “my experience is that if you find yourself on the opposite end of the economic spectrum, it’s really difficult to stay healthy, and eat organized, and eat well” also spoke to the bi-directional nature of HFI and health, and described the difficulty that food bank members have in maintaining healthful behaviours given their financial challenges.  In contrast to viewing the food bank as a long-term resource, 10% of survey participants selected ‘don’t know’ to the question of ongoing use, and 1 focus group participant stated that they saw the food bank as a temporary measure. Dialogue from this participant expressed hope in overcoming health challenges and finding employment in the near future, explaining that their use would end once they started making income again.    4.4.3.2 Experiences and visions for the future of the food bank system Food bank as a support and a distress The majority of survey respondents (81%) agreed that their overall experience at the food bank was positive. Gratitude for food bank provisions as a resource for members to save money on their food budgets was widely expressed across all focus groups, as “whatever you can save   67 on food you can put into something else.” The food bank was seen to provide an important service, with one participant stating that she “wouldn’t have made it if it weren’t for the food bank”. The sense of community that participants found at the food bank was also revealed in three of the focus group discussions, and the line-up was even reported to serve as a major socialization space for one member who had been “isolated for a long time”. However, sentiments indicating that participants would prefer to not require these services, and the distress felt in needing these services, remained evident throughout the discussions. As one participant stated “If I can avoid it, I will avoid it”, and reflections on the loss of dignity that many experienced when they first began using the food bank were apparent across all focus group discussions. Described by coming to terms with financial changes, and the loss of pride that many participants experienced, one participant reflected that coming to the food bank was a “humbling” experience, and overcoming the “feelings or perceptions of social stigma” and “feelings of humiliation” were expressed by others.   Food provisions The theme of food provisions included all focus group dialogue regarding the food items offered at the food bank or how they could be improved. These were prevalent across all five focus groups, with major subthemes being the quality and quantity of food provided. In line with operational changes at the food bank organization, some focus group participants reported that the food items being offered had improved, or that healthy options were being provided – “I think they have changed it so much for the better, and it’s unbelievable. Just more fruit, and more healthier stuff.” However, poor quality and “expired” foods did remain an issue for the majority of participants. All five focus group discussions included conversations regarding inadequate quantity of food items, with the experience of unmet need being described by one participant, as “the food I get here is not enough to keep me going”. The majority of survey participants also responded ‘no’ or ‘sometimes’ (62%) to whether food bank provisions were enough to meet their household need. Only one focus group participant reported the quantity of food provisions to be of adequate quantity. Throughout the focus groups, participants also revealed the role of allergies as further limiting the amount of food that they were able to take home, due to lack of choice and limited availability of items that met their restrictions. One participant described the impact this had on   68 the ability of the food bank to assist her family, stating that her “daughter has allergies. I sometimes don’t leave here with any food for her.” Dietary restrictions limiting participants’ ability to use food bank items were also reported by 48% of survey participants, and primarily included dental issues, allergies, and disease related conditions.  Participant recommendations for improved food provisioning related to specific food items that would be desired from the food bank, and these preferences focused around providing more “nutritionally oriented foods”, and improving the quality and choices of the items provided. Preferences for more meat and alternative protein items, fresh fruits and vegetables, and milk and alternatives dominated the focus group conversations. These three food groups were also the most prevalent requests amongst survey respondents, with 73%, 65%, and 43% of participants requesting items within these categories. Offering greater choice and selection, and reducing the amount of “expired” foods were also noted to be valued throughout the focus groups. One participant felt strongly about this, stating that “yesterday, at least two of the things we received were expired. They are out of date. Quite frequently you’ll get tomatoes that are rotten. Yes you can chop it off, but there is this mentality that you can give any s*%t to homeless people or to people on this end of the economic spectrum because they don’t matter. So just cut the distribution of expired goods.” Participants felt that a helpful way to address this was to improve linkages with food producers, such as farmers and local grocery stores, in order to procure food items that are “current” or “really fresh”. However, some participants did reflect that the presence of foods past their sell-by date was not an issue for them, seeing these items as a way to increase the quantity of food items available at the food bank, and recognizing that “there’s a difference between expired and best before.”   Service delivery  The theme of service delivery was related to how services were or could be delivered at the food bank, including the format of food pick-up, accessibility, and overall environment or dynamics at the site. Survey results described high levels of agreement to feeling physically safe at the food bank (80%), as well as feeling respected by food bank volunteers (87%) and other members (80%). However, although the vast majority of survey participants agreed that they felt safe and respected at the food bank, the fact that 20% of survey participants did not was of concern. All five focus group discussions revealed issues with the “dehumanizing” line-up style   69 of food distribution, that reported concerns with bad weather, queue jumpers, cigarette smoke, and long waiting times, including having to “stand there for two hours sometimes”. The stressful atmosphere, explained by experiences with aggressive and pushy behaviour and feelings of stress and anxiety at food bank sites, was also a primary concern. One participant reflected that the aggressive behaviour was due to worry regarding the limited availability of food and high levels of need, reporting that “some people behave aggressively because they think there is not going to be any food anymore, so they want to be the first one. It’s like a battleship.” Another related that she had difficulty bringing her child to the food bank, due to the behaviour of other members. Furthermore, the restricted availability of the service due to the limited days and hours of operation were also revealed as an issue related to service delivery in two of the focus groups. Participants’ discussions regarding improving service delivery focused on measures that would improve accessibility, reduce the line-up size, and increase safety and respect at the food bank. Increasing the accessibility of food banks by expanding the time frame and number of food banks was thought to be an effective way to reduce line-up size. Additionally, allowing members to access the food bank more frequently and introducing a food bank delivery service to support those with mobility issues were specified throughout focus group conversations as measures that could improve accessibility. Adjustments to staffing, including increasing security support and sensitivity training for volunteers, were determined to be areas that food banks could focus to promote a more welcoming environment and greater feelings of safety and respect at the sites. Although only discussed in one focus group, making the food bank line a smoke free environment was also seen as a simple way to make the food bank more comfortable for those members who don’t smoke.   Additional services The majority of survey participants (77%) reported an interest in having additional services available at the food bank. Participant narratives throughout the focus groups included connecting with organizations that could provide health and wellness services with a focus on counseling and mental health support - “Counseling. I think that is good, because it’s all part of the system. It (mental health concerns) often comes when people are struggling. Help is not cheap”. Ideas included having care practitioners from the local health authority on-hand to provide services, and offering opportunities for free counseling and emotional support, which   70 were described as difficult to access. Linking with these services was discussed as a potential opportunity that the food bank could harness to provide better health support for their members. In terms of food related programming, survey results revealed that the vast majority reported good or excellent cooking skills (75%), almost all had access to kitchen facilities required for food preparation, and throughout the focus groups no members specifically reported lack of personal food skills as a challenge that they face. However, focus group discussions did reveal a desire for additional services that relate to food preparation, as focus group participants suggested recipes be handed out with some of the less familiar items that they receive as well as offering community kitchen programs where they can cook foods together.   Desires and goals Participants provided a variety of suggestions that could help to improve food bank services to better meet their needs, however, goals for their personal futures largely displayed the desire for improved life factors that would diminish their need for the food bank – namely improved financial situations. Employment was the most reported goal, including desires for “stable employment” and “more jobs.” Improving income assistance rates was also seen as a necessity in order for some participants to achieve food security. Many participants reflected that this could only be met through policy and government interventions, as revealed in multiple comments including - “I hope the government gets its priorities straight, and starts taking care of the people. That’s a dream come true. Where people come first.” However, some joked “winning the lottery” was their only way to improved food security– “I only have one hope. Fifty million.” Improved health was also mentioned by a few participants, and included wanting to be able to return back to their “normal life”, getting their “health and fitness back”, and experiencing “less stress” and “not having to worry.” Indicating some untapped potential for community capacity building amongst the food bank community, some participants revealed that they wanted to be in a position where they could be able to give back to their communities, and 55% of survey respondents agreed that they had skills and knowledge that they could share that would benefit other members at the food bank. Although food banks are limited in their ability to provide financial security to participants, some focus groups reflected on the role that the food bank could play in assisting them to attain these goals. In addition to offering services related to participants’ health and   71 mental wellbeing, some participants desired opportunities to access job and volunteer opportunities at the food bank. Providing an avenue for their clients’ voices and experiences to be heard across the wider community, and playing an advocacy role for larger public policy change were also suggested. One focus group unanimously agreed that the food bank organization could offer better support by “being more out in the public… the main public thinks the food bank gets everything satisfied in your life.” Another focus group participant reflected that more political pressure was needed, “we should actually be looking at some sort of organized pressure onto the government. You know, volunteers from all over the country that have been handing out food, picking up food, using up all their own time, when it’s the government that has placed us in those positions”; and other participants believed that the food bank could take a stand by using a rights-based argument when discussing hunger with the public, indicating a desire to have “the food bank in the media, that good food is not a privilege, but a right.”   4.5 Discussion Food banks in Canada are being used by a greater number of individuals than ever before. However members’ experience of the food banking systems, and their views on these services, remain an area of limited research. The purpose of this study was to draw upon the experiential knowledge of food bank members in Vancouver to understand if and why the food bank is used as a long-term food augmentation resource, and to understand how food bank members envision food banks transforming to better support their needs. These findings will assist to identify strategic opportunities for food bank organizations and others to support improved community food security.   4.5.1 Food banks as a long-term resource Though food banks are utilised in both a short and long-term manner, individuals who projected requiring the food bank over the long-term were found to far outweigh shorter-term cases. Aligning with other North American studies that have found chronic food bank use (21–23,59), these counter the characterization of food banks as a short-term or emergency support system, and confirms that for many members it appears to have become a necessary strategy to   72 navigate the effects of long-term unemployment (21), disability and health concerns, and an inadequate social safety net. As Kicinski reports (21), in 1986 Christner and Sterling recognized in their work with food bank members that their food needs were more than temporary, and resulted in their discouragement of using the word ‘emergency’ to define these services. Although evidence has continued to show that food banks are providing a long-term service (22,23), some food banking organizations continue to use the term ‘emergency’ to describe the services they offer. This characterization may inadvertently be adding to the conceptualization of food banks as a temporary service, disconnecting needed public attention from larger social policies that are setting the stage for ongoing use by some members (56).   4.5.2 Experiences and visions for the future of the food bank system Participant reflections on their experiences and visions for change fell within each of the three phases of the community food security continuum. These included efficiency stage issues and improvements that food banks can adopt over the short-term, ideas for programs and improved linkages between food banks and other agencies/food system players to enhance the medium-term participation stage, and incorporating more messaging to support political will towards long-term solutions and re-designing our societal approach to reducing food insecurity. I will discuss each of these stages below.  Stage 1: Efficiency level measures Inadequate food quantity was highlighted throughout focus group discussions and survey results, aligning with Canadian research with food bank operators (17) and food insecure families (24,28) that describe the food bank as inadequate to meet the food needs of their members. The prevalence of dietary restrictions amongst our sample also indicate additional challenges as the lack of choice and autonomy in food selection is further impacting the ability of the food bank to support the proportion of their members with dietary restrictions. Furthermore, negative insight into the quality of the foods provided, especially “expired” or rotten items, was also readily expressed by participants, and have also been reported in various other studies (17,27,28,37). These issues of inadequate quantity and quality have been attributed to the charitable nature of food banks, including reliance on inconsistent donations, limited storage, and other logistical issues that food banks face (17,27). In the context of this study, where this   73 specific food bank organization has been making changes towards improving the quality of foods offered, these findings emphasize that despite their efforts these issues remain difficult for food bank organizations to address.  Efforts to reduce food waste, including laws passed to provide fiscal incentives for food distributors and farmers to donate surplus food to food banks, are increasing across the western world (118,119). While seen as a viable avenue to improve access to food for individuals without financial means to obtain them, corporation-focused incentives place increased pressure on charitable organizations to effectively sort and distribute these food items, with no government support or assurance that these items are of the quality or type required by their members. Recommendations for improving the quality of food provisions revealed in this study included providing more healthy nutrient-dense food items, such as protein-rich items, fruits and vegetables, and milk and alternatives. Related to financial constraints, these items have been found to be purchased less by low-income families (120), and all have previously been identified by food bank members as desired items (96,121,122).  However, policies to reduce food waste and increase food bank donations would not ensure that these more desired food items make their way onto food bank shelves (17,27,78). The capacity of food banks to safely distribute large quantities of foods like fresh meat and milk products, which pose increased difficulty for safe food handling and potential foodborne illness, also remains questionable as these charitable pathways don’t always have the appropriate storage facilities to keep these foods within acceptable temperatures. These limitations remain vital areas for food banks to negotiate with other food systems actors, in a way that upholds and provides voice to their members’ preferences and needs.  Additionally, products coming through these pathways may be past their ‘best before’ date. Our findings show that food bank members have concerns about the consumption of these products, and the questionable ethics of providing unmarketable food items to vulnerable citizens has long been emphasized (15,55). However, ‘best-before’ dates only provide indication that food products have passed the anticipated time frame that ensures they have retained the freshness, taste, nutritional value, or specific qualities claimed by the manufacturer (123), and are generally present as a protection to the food producer or brand rather than the consumer. Although these foods may not be seen as ideal, they are safe to consume, and their re-distribution does assist to keep edible food from the landfill. Given some participants’ descriptions of these   74 dates as “expiry” dates indicates that there may be a lack of understanding regarding the meanings of these dates and terms. Very few products in Canada are required to have expiry dates (123), none of which would be permitted to be provided through a food bank if the expiry date had passed. A better understanding of the definitions of food labels could assist food bank members to make educated decisions regarding their choice to consume the food items or not. Furthermore, fostering greater discussion and dialogue of the food bank system as a sustainable and environmentally friendly agent for surplus food utilisation may assist to lessen some of the stigma surrounding the consumption of these food items.   Increasing member autonomy in food selection is also an area food banks can work towards. The practice of permitting choice has been previously noted to improve the ability of food banks to better tailor provisions to members’ preferences and needs (27), and was recommended by study participants. This could serve as an avenue to ensure that those limited by dietary restrictions have more options, and leave the food bank with a greater amount of appropriate foods. It would also provide an option for members to elect whether or not to choose food bank items that are past their best-before date depending on their personal preferences regarding the consumption of these foods. Additionally, ideas relating to the use of coupons as a method to provide members with the autonomy to purchase preferred foods independently were suggested in both the focus groups and surveys. Recently, as a measure to allow for more normal and dignified food access, an organization in Ontario, Canada shut down their food bank and began facilitating a program that provided cash cards to local grocery stores (124). Although this program change was not evaluated, as an efficiency stage measure this strategy could potentially be an effective method to increase member autonomy. However, this system still relies on charitable donations from members of the community in order to function, and does little to address the capacity of food insecure individuals to obtain adequate, stable income.  Issues with service delivery at food banks, namely due to the line-up system and anxiety about scarce food supply, have previously been found to impact the ability of food banks to provide a dignified space for food access (21,28). The loss of dignity and feelings of shame that this study found amongst food bank members has been revealed as a concern amongst participants in previous research by Tarasuk et al (24), and was further reported by 11% of food insecure families in a Canadian neighbourhood as the main reason they elected to not use food banks (28). Despite this, there was evidence throughout our study that the food bank was seen as   75 a space where members accessed community. By drawing on this capacity, food banks could better support the dignity of their members by playing a central role in community building. Creating safe supportive environments that foster inclusiveness and respect could advance food banks’ roles in supporting health promotion and psychosocial health (125), in this case by reducing social isolation and assisting to mitigate feelings of shame. This would not only help to develop their role as an efficiency level service, by making their environments more comfortable and approachable for individuals experiencing HFI, but can additionally help to lead organizations into the participation phase of the community food security continuum.   Stage 2: Participation and Transition  Offering additional programming and linking with other organizations that can provide additional services were seen as valuable pathways that the food bank could harness to better support their members’ wellbeing. Chronic disease and mental health concerns were prevalent amongst our sample and have been found to be experienced disproportionately amongst food insecure populations (63,67,126). Linking food bank services with health related programming could provide greater access to health services, such as mental health support, which was indicated as a primary concern throughout our focus groups. Recognizing that public health interventions are most successful when they occur in the spaces that people regularly inhabit (127), programs that integrate food bank services with additional forms of health support have begun to emerge across North America. For example, three food bank networks across the US found that members accessed nutrition education resources, health screenings, and health treatments such as immunizations and dental care when they were offered alongside traditional food provision services (128). Another study in Hartford, Connecticut found that introducing one-on-one support and goal planning with members of a food bank resulted in significant increases in self-sufficiency ratings and fruit and vegetable intake (82). Food banks are established within local community settings and are well positioned to engage with vulnerable populations. Our study determined that food bank members envision a future where organizations are developing these linkages.  Given the focus that community food security initiatives have placed on food-skill development (19,48), the study survey also assessed self-perceived cooking skill and access to food preparation facilities. The findings suggest that lack of food skills was not a perceived   76 barrier, in line with other research that has found food insecure households act resourcefully in order to make the best with the limited financial resources they have (19,26). However, participants in our study revealed that reliance on unusual items combined with lack of autonomy over food selection posed a challenge for food preparation. As described above, offering participants more selection may assist to aid this issue (27), as well as offering recipes and cooking ideas for items that make their way through the food bank.   Stage 3: Re-design Ultimately, food bank members expressed desire to improve their financial situations in order to diminish their need for the food bank altogether. Member-identified framing of their food-need as an economic issue aligns with the understanding of inadequate financial resources as the root cause of food insecurity in Canada (2–5,26). Limitations in individuals’ abilities to improve their financial situation were revealed in focus groups as the primary reasons participants viewed the food bank as a long-term resource. These suggest that many food bank members acknowledge food assistance as an essential component of their food access strategy due to factors over which they have little agency – such as significant health challenges, income assistance rates that do not appropriately reflect the cost of living (46,79,129), high housing costs (130), and lack of access to stable well-paying employment (21). In Canada, federal and provincial income support programs are offered through employment assistance, child tax benefits, and rental assistance to provide increased access to income. These programs are thought to assist in reducing food insecurity by increasing financial resources available to spend on food (16); however, a growing body of literature questions the capacity of these programs to do so at their current benefit levels (2,15,29). Recent cross-sectional data on food banks across Canada have reported that 69% of current food bank members are receiving income assistance, disability related assistance, or employment assistance, indicating that some individuals receiving these types of benefits need to seek out other resource augmentation strategies in order to make ends meet (20). Other studies that have reviewed income assistance programs as a measure to protect against HFI have found that 56% of those reliant on income assistance report experiencing food insecurity (39) and have three times higher odds of experiencing HFI than those not receiving this assistance (1). Not surprisingly, opportunities for employment, and advocacy efforts that support improved understanding of food bank members’ situations and highlight the inadequacy   77 of government policies and social assistance were envisioned by members as important avenues that food bank organizations and others can take to better support long-term food security (56).   4.5.3 Strengths and limitations A primary strength of this study included the close research relationship developed through the CBPR approach. This approach was practice oriented, and assisted to fill organizational knowledge gaps. Furthermore, engaging directly with food bank members gave voice to their experiences and solutions, and many expressed their appreciation that the food bank was interested in including them in this process. This engagement reveals that the use of CBPR could potentially be a useful and informative way to undertake evaluation of food bank services. Limitations of this study should be acknowledged in the interpretation of findings. As our survey relied on a relatively small convenience sample of food bank members, results may not be generalizable to the larger population of food bank members. A limitation to the qualitative component was the fact that our study design only included a single focus group conducted at each of the five sites, and analysis occurred after and not throughout the data collection process. Therefore, the ideal of saturation cannot be determined to have been achieved (93). However, strengths of the mixed methods data analysis process that included triangulation and comparison of two different sources of data, as well reviews with food bank members during the knowledge translation process to obtain participant and member feedback, were used to confirm that data was accurately represented (89,92). Furthermore, given the number of studies reporting similar challenges within the food banking system, our findings appear to be in line with evidence that questions the current capacity of charitable food systems to respond to the needs of those who use them. It should be noted however, that participants in our study were only active food bank members, who were willing to navigate the negative issues they reported to be present at the food bank. It is known that the majority of food insecure households elect not to utilize the charitable food banking system (7,28), and therefore, our results do not speak to the experiences of all food insecure households in Canada.    78 4.6 Conclusion This study was designed and conducted in partnership with a community food bank organization in Vancouver, and aimed to provide insight into the challenges faced by food bank members, and their visions for an improved food bank system. Findings suggest that food bank use in Vancouver is experienced in the context of severe financial constraint due to issues out of members’ immediate sphere of control. Food bank members reported high prevalence of unemployment, reliance on government disability income support, and health issues including mental health concerns and chronic pain and most expected to their use of food banks to continue. Although appreciation for food bank services was apparent, issues surrounding quantity and quality of food provisions, and safe, dignified food access remain challenges. Despite current limitations of food banking services, members envisioned these organizations transforming to better meet their needs. Strategies to improve services include increasing the quality and choice of food provisions, focusing on the creation of safe and welcoming spaces, providing greater integration with health care and health promotion activities, and taking a position in advocacy efforts aimed at poverty reduction. Together these changes will assist food banks to improve their capacity to support their members; by providing more dignified, healthy food access, and facilitating discussions towards a more effective response to the underlying issues of hunger.    79 Chapter 5: Conclusion  This thesis outlines research undertaken as part of an exploratory study with the GVFB, and serves as the first step in building a CBPR program with both the GVFB and their members. The purpose of this research was to learn more about food bank members, understand their experiences, and explore how they envision food banks updating to better support their needs. In order to bring superior insight to participant responses, and given the gap in mixed methods literature among food bank members, a convergent parallel mixed methods design was used to answer these objectives. It consisted of both quantitative and qualitative studies that were conducted in parallel at five GVFB sites in the GVRD over the summer of 2015. The first quantitative study conducted a survey to provide a description of the characteristics of a sample of food bank members, and determined whether any characteristics were associated with the most severe form of food insecurity. The second study explored if and why food bank members saw the food bank as a long-term resource, and described food bank members’ experiences and visions for the updating of the food bank system. It followed a mixed-methods design that allowed for the integration of aggregate data from the survey used in the first study, with the in-depth exploration of the qualitative experiences of food bank use through focus group discussions. The two forms of data were joined to bring greater insight to food bank members’ experiences, and to develop a participant envisioned framework on how food banks can transition along the community food security continuum.  5.1 Contributions and significance  This thesis contributes to the literature by providing insight into the experiences of food bank use and HFI amongst households who access food bank services. There has been a lack of published research seeking to understand why and how food banks are being used, how their use interacts with severity of HFI, and how members envision food banks transforming to better meet their needs. An exploratory mixed-methods CBPR was used to encourage identification of issues that are most relevant to the community for which the research serves, with an aim to utilise this knowledge towards further action and empowerment of the food bank member community (89).    80 Findings highlight the situations of poverty faced by our sample of food bank members, as most lacked resources such as income, employment, and good health. Aligning with other studies on food bank use in Canada, we found that very low incomes and receipt of government income assistance and disability assistance were highly prevalent amongst this sample of food bank members (20,23). Furthermore, the number of single-individual households being assisted by the food bank indicates this group as a particularly vulnerable demographic, often marginalized in updates to social policies (115) and in discussions of deservedness for food assistance (56). This study additionally confirmed severe HFI as prevalent amongst food bank members in Canada (24,28,63,73), and further determined that, among the variables assessed, only income related factors were associated with severe HFI in this sample.  Results from both qualitative and quantitative sources revealed that the majority of this sample of food bank members used the food bank as a long-term, regular strategy to assist in the management of inadequate finances, static social assistance rates, and competing financial demands. A lack of personal agency in addressing these barriers was determined, as the majority believe they will continue to need the food bank in the future. These findings corroborate previous suggestions that unemployment could be a primary driver for ongoing long-term food bank use (21–24), but additionally emphasize that some food bank members may be limited from paid work due to conditions and disabilities that impede their ability to maintain steady employment.  In line with previous studies looking for relationships between HFI and food bank use (23,28,74), quantitative findings determined no associations between the prevalence of severe HFI and food bank usage patterns, and indicated high levels of severe HFI regardless of level of use over the past year. Furthermore, the majority of our survey participants reported no decrease in their hunger since first using the food bank, and both quantitative and qualitative findings suggest inadequate quantities of food are being provided through the food bank. Together, these suggest that this food bank does not currently meet the household needs of some members. This disconnect between food bank service provisions and member need have been previously reported by food bank operators and volunteers (17,19,27), supporting the claim that charitable food provisioning is provided as a “symbolic gesture” as opposed to an adequate and accountable resource (131).    81 Overall, evidence from both quantitative and qualitative data suggest that food banks are an insufficient response to the food insecurity experienced by their member community, and emphasise the importance of improving the underlying economic issues leading to poverty in Canada to reduce the experiences of food insecurity in a meaningful way. HFI in Canada has been well documented as being associated with insufficient purchasing power to obtain food (1–7), and recent research has revealed that interventions that provide adequate income could help to reduce HFI (113). The Canadian Guaranteed Income Supplement program for low income seniors over 65 provides top-up funding to bring these individuals above the poverty line, and has been associated with lower prevalence of food insecurity amongst seniors when compared to those under 65 (113). A recent position statement, released by Dietitians of Canada, included the recommendation to ensure “all households have consistent and sufficient income to be able to pay for basic needs, including food”(132) and outlined a comprehensive list of components for the strategy that emphasized improved income security for households who rely on unstable or low wages, increased social assistance rates, and greater investments into affordable housing – all of which were highlighted as issues for this sample of food bank members. Together these research findings and recommendations stress that policy efforts and interventions that are designed to increase income may be the most effective and global way to decrease HFI and overall food need, and encourages further income-based interventions and evaluation.  Nevertheless, until viable and working policy options are adopted in Canada, food banks remain an important fixture on the food security landscape. Some food bank members in this study and others (37) have reported viewing food bank services as an important resource, and indicated that it does provide assistance in relieving their experiences of inadequate food access and hunger. Our study further revealed that participants view food bank services as capable of being updated to better support their needs. This envisioning, utilising the knowledge of members’ lived experience, relates to how food banks can better situate themselves across all stages of the community food security continuum (Table 5-1). In their efficiency level role in the food security movement, as a provider of immediate food-based assistance, food banks can better support their members by improving the quality and quantity of food provisions, and adopting measures which can increase members’ autonomy over the foods they receive. These changes will assist to make services more attuned to members’ needs and dietary requirements. Furthermore, by fostering a safe and welcoming environment in   82 the spaces where they provide their services they will make the process of attending the food bank more comfortable for members, providing both efficiency level updates and helping to develop their role as a community builder in the participatory stage. This movement into the secondary participation stage, by linking their services with health agencies and mental health support, will allow them to draw on their position as an established resource that is already being accessed by a target vulnerable community to promote greater health access for their members (127).  Looking forward, towards re-designing community action for greater food security, wider public policy changes and advocacy efforts were envisioned by members as vital to ensuring adequate access to food. Research teams in Canada have been working to provide data on the economic factors associated with food insecurity (1,15), and some food bank organizations are becoming more involved in advocacy efforts aimed at educating the public about the underlying factors of food bank use and poverty reduction (20,48). For example, Community Food Centres Canada runs a community action program (133), to provide space for food bank members to share their experiences with poverty, receive training on civic engagement, and access links to advocacy initiatives such as the Put Food in the Budget campaign. Participant dialogue expressed throughout this study supports that these actions are important and desired components of food bank organization updates. Determining how food bank members can engage as actors in these various processes and evaluations of food bank service updates appears to be the next step for success in the CBPR approach.      83 Table 5-1 Recommendations to improve food banks services Stage 1: Efficiency Current situation/issue Recommendation Food quantity and quality reported to be inadequate to meet needs. Increase provision of protein rich foods, fruits and vegetables, milk products. Work with producers and retailers to improve food donation quality.  Lack of autonomy over food selection limits members’ ability to cater to preferences and dietary restrictions. Allow members to select their own items.  Provide coupons to obtain food through normal avenues (supermarket, grocery store, etc.)  Concern with poor quality and “expired” foods being provided. Potential lack of awareness regarding best-before dates. Provide education on food safety labelling, to allow members to make their own educated choices over which foods they will consume. Participate in dialogue regarding food waste, and consumption of non-saleable food items from a sustainability or environmentally conscious perspective. May assist in decreasing stigma. Quality control to ensure that no truly 'expired' or inedible products make their way to food bank members.   Service delivery impacted by stressful environment and limited pick-up times. Volunteer and staff training to promote safe and welcoming environment. Improve access by increasing locations, and time frames for food collection.   Non-smoking line-up. Provide delivery service for those with mobility issues.   Stage 2: Participation and transition Current situation/issue Recommendation High prevalence of health concerns, desire for increased health support. Link with health promotion and mental health services, including counselling support.   Interest in increased food programming Provide opportunities for members to increase their food literacy and food program participation: recipes, nutrition education, community kitchen programs, and community gardening.   High prevalence of unemployment, and desire to give back to their community. Provide work, volunteer, and skill building opportunities for interested members, or link with organizations that can offer these opportunities.    Stage 3: Re-design Current situation/issue Recommendation Members report to experience little agency over factors (unemployment, disabilities, social assistance benefit rates) that limit their ability to obtain adequate financial resources to afford food. Support advocacy for poverty reduction and policies that will improve financial access to food. Create opportunities for members to share their stories and inform public understanding of food bank use.    84 5.2 Strengths and limitations  Strengths and challenges stemmed from the CBPR framework of this study. Strengths came through our partnerships, as we were able to establish a connection between community-based actors and two local universities to develop research that can contribute to social change. The collaborative design ensured that questions asked were relevant to the food bank organization’s needs, and results gave voice to participant experiences and visions for change, an important aspect of the community food security movement. The support of the food bank organization in the community engagement, implementation, and knowledge translation phases of the research process facilitated the research team to build trust with each food bank site, their volunteer communities, and their members. Although only able to be piloted on a small-scale in this study, the addition of the peer research assistant (PRA) in the survey component was fruitful. The presence of this individual on the team provided valuable insight into how to best meaningfully and respectfully engage with food bank members, and the development of this role provides a model for a PRA training program to be introduced in future iterations of this research.  Challenges of the CBPR approach related to the preliminary nature of this research partnership and the process of developing and conducting research with a dynamic organization undergoing change. Initial research plans proposed to recruit from a larger member base by sampling from a wider number of sites, repeated longitudinal follow up, as well as greater focus on nutrition analysis of member dietary patterns and food bank provisions. However, as the food bank organization had not previously conducted research with their members, they desired that we approach this work with caution. This played a large role in the design of this initial exploratory study. Original aims for survey recruitment had been to include six of the thirteen sites; however operational and organizational constraints and preferences of the originally proposed partner sites limited the number of sites available for recruitment to three. Although ideals for higher levels of participation, random selection used for survey recruitment methods, and longitudinal follow-up would have made for more rigorous science, the process of engagement and facilitating an open and inclusive recruitment were prioritized as targets for this initial exploratory phase. These goals resulted in well-developed protocols and procedures for conducting research with this organization; however, they also created two major limitations in the study design. Firstly, the cross-sectional nature cannot provide evidence regarding a causal   85 relationship between food bank use and severity of household food insecurity. Although we were able to access retroactive food bank use data, HFI status was only measured at one single time point, and therefore changes to HFI status could not be determined. Secondly, due to feasibility and the preference of our community partner we utilized a non-probability convenience sample from a limited number of sites. This, in combination with a low participation rate, affected the representativeness of our sample and the ability to generalize these findings to the larger GVFB member population. Participants in our sample were self-selected and might have had particular attributes or personal experiences that influenced their interest in participating in our study. For example, it is possible that longer-term members may have felt more comfortable taking part in our survey, and due to our extended time on site there may have been the potential to recruit more frequent users. The fact that survey and focus groups were not offered in multiple languages also excluded the non-English speaking subpopulation of food bank members. It also remains worthy of mention that this study only selected from participants actively accessing food bank programs. By recruiting only currently active members of the food bank, our results may include the effects of ‘survivor’ bias, in that we were only recruiting individuals who continue to use the food bank and not those who have used it in the short term and then made their way out of the system, potentially due to improved HFI or only a short-term need. These methodological factors reduced the representativeness of this sample and generalizability to all food bank members, and limited the capacity to develop a descriptive profile of all GVFB members. However, a strength of this study included the capacity to access data that provided aggregate demographic and length of use characteristics for the larger GVFB population accessing these services. Although we were only able to access three variables through this system, we determined that in terms of gender and smaller household sizes (one and two) our survey sample was comparable to the total GVFB population using the three food bank survey sites over the study timeframe. Conversely, when looking at length of use, as postulated above, the sample did over-account for longer and more frequent users (Appendix G). Although study findings are not likely representative of all food bank members, it does provide information on an important sample of the population. This group’s high prevalence of severe HFI, regular/ongoing food bank use, and dependence on social benefit programs is especially of interest as it indicates these individuals are particularly vulnerable. Furthermore, given the   86 similarity of our results to other investigations of food bank members (20,21,23,63), the effect of convenience sampling and self-selection might be minimal.  On the topic of measures, there were strengths to our survey and focus group questions. Questions were developed through close collaboration with our community partner, and survey questions were carefully selected from validated questionnaires wherever possible (70,101,102). The survey and focus group questions then went through multiple rounds of review by content experts from the research and GVFB management team. Through this process question wording and order were adjusted, and specifications were developed in order to improve clarity and construct validity. Additionally, the survey went through a round of piloting with individuals in the food bank member community in order to determine that questions were appropriate and understandable by this audience.  One limitation to our survey was that our questions relied on self-reported indices for the majority of variables; therefore findings were subject to recall and/or desirability bias, which may have resulted in some systematic error. However, survey development, administration, and collection of usage data aimed to reduce this. Firstly, time frames for survey questions requiring memory were kept short wherever possible (i.e. over the past month), to reduce potential for recall bias. Secondly, the selected survey administration format aimed to reduce bias by training interviewers to remain neutral to participant responses, and follow survey wording and order exactly (100). Thirdly, frequency and length of use were collected using the GVFB database, which offered a direct report of food bank use and was not subject to recall bias.   Another limitation for the survey relates to the tool used to measure HFI. The HFSSM asks specifically about financial access to food (39), which may not be the best way to look at change in hunger through the use of the charitable food system. Although the food bank offers additional food items that potentially allow a household’s food dollar to last longer each month, it does not provide additional funds for food leading to recognition that this tool may not adequately measure the impact this service has on severity of food insecurity. In order to address these concern, and in an attempt to determine relational construct validity (93), we asked additional questions to specifically elucidate the food bank’s effect on participants’ hunger. From these we were able to determine that although some participants reported that the food bank provided enough food to meet their needs and that their hunger had decreased through food bank use, the majority of participants did not. However, there was no significant association between   87 these two measures and reporting of severe HFI (Appendix F3), further suggesting that the HFSSM may not have the appropriate construct validity to measure of the food bank’s impact on food access and hunger change amongst food bank members. The HFSSM remains the best measure with which to monitor and compare food insecurity to nationally collected data (39). Although the issues that food banks aim to address, namely preventing individuals from going without food, are experiences captured by the HFSSM, additional tools that seek to specifically measure the impact food banks have on addressing immediate food need would be beneficial in future evaluative studies of these programs.  Though there were various limitations to this study, the strength of the design lay in the mixed methods approach. This analysis process allowed for triangulation and comparison from two data sources, combining information on the characteristics and preferences of a wide group of participants with in-depth exploration of participant experiences to explore our research questions and compare findings.   5.3 Application of findings This thesis outlines practices and policies envisioned by food bank members regarding the movement of food bank organizations and other parallel agencies across the community food security continuum. By offering a participant framed understanding of the role food bank organizations play in their lives, and the underlying issues that result in a long-term requirement for these services, it offers valuable insight into how these organizations can position their services towards more relevant and permanent solutions to hunger. This work also reveals that future programming and research that creates space for food bank members to be directly involved, including design, data collection, interpretation, and knowledge translation out to the larger community, can be a valuable avenue to support member empowerment and advocacy for member-directed solutions to address food insecurity in Canada (88,89,91).   5.4 Future research direction To avoid the previously mentioned methodological concerns, future research should aim to improve study design to be more generalizable to the larger food bank member community. This includes the potential of randomly selecting study sites, or recruiting a random sample of   88 food bank participants. Future studies should also explore and implement methods for accessing members who are non-English speakers. Furthermore, as our study was only able to look at HFI and retrospective food bank use, future research should focus on longitudinal evaluation of food bank use and food insecurity outcomes. Although the HFSSM remains an important measurement tool to compare HFI of food bank members to national data, this tool is not likely to discern the true impact of food bank use, as it is not likely to measure decreases in hunger brought on by charitable food assistance. Other measurement tools of HFI should be included to look for impact of food bank use on HFI. While longitudinal research has yet to determine the effect of frequency of food bank use on food insecurity, evidence from this thesis joins a growing body of studies that suggest that food bank interventions are a helpful but insufficient response. As Canada continues to face a rising prevalence of food insecurity, alternate avenues to support and empower affected individuals remain desperately needed. Public policy changes that address poverty, low incomes, and access to affordable housing, while ensuring inclusivity for single individuals in these agendas, appear to be priority areas that research and policy makers should focus on to reduce HFI.    89 References  1.  Tarasuk V, Mitchell A, Dachner N. Household food insecurity in Canada, 2012 [Internet]. Toronto (ON): Research to identify policy options to reduce food insecurity (PROOF); 2014 [cited 2014 Jan 1]. Available from: http://proof.utoronto.ca/resources/proof-annual-reports/annual-report-2012 2.  Power E. Individual and household food insecurity in Canada: position of Dietitians of Canada. Can J Diet Pract Res. 2005;66(1):43–6.  3.  McIntyre L, Bartoo AC, Emery JH. When working is not enough: food insecurity in the Canadian labour force. Public Health Nutr. 2014;17(1):49–57.  4.  Tarasuk V, Vogt J. Household food insecurity in Ontario. Can J Public Health. 2009;100(3):184–8.  5.  Power E. Determinants of healthy eating among low-income Canadians. Can J Public Health. 2005;96(3 Suppl):S37–42.  6.  Che J, Chen J. Food insecurity in Canadian households. Health Reports. 2001;12(4):11-22 no. 82–003–X.  7.  Vozoris NT, Tarasuk V. Household food insufficiency is associated with poorer health. J Nutr. 2003;133(1):120–6.  8.  Kirkpatrick S, Tarasuk V. Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. J Nutr. 2008;138(1):604–12.  9.  Tarasuk V, Fitzpatrick S, Ward H. Nutrition inequities in Canada. Appl Physiol Nutr Metab. 2010;35(2):172–9.  10.  Okechukwu C, El Ayadi A, Tamers S, Sabbath E, Berkman L. Household food insufficiency, financial strain, work-family spillover, and depressive symptoms in the working class: the Work, Family, and Health Network study. Am J Public Health. 2012;102(1):126–33.  11.  Gucciardi E, Vogt JA, DeMelo M, Stewart DE. Exploration of the relationship between household food insecurity and diabetes in Canada. Diabetes Care. 2009;32(12):2218–24.  12.  Seligman HK, Bindman AB, Vittinghoff E, Kanaya AM, Kushel MB. Food insecurity is associated with diabetes mellitus: results from the National Health Examination and Nutrition Examination Survey (NHANES), 1999-2002. J Gen Intern Med.   90 2007;22(7):1018–23.  13.  Berkowitz SA, Meigs JB, DeWalt D, Seligman HK, Barnard LS, Bright O-JM, et al. Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study. JAMA Intern Med. 2015;175(2):257–65.  14.  Tarasuk V, Cheng J, de Oliveira C, Dachner N, Gundersen C, Kurdyak P. Association between household food insecurity and annual health care costs. CMAJ. 2015;187(14):E429-36.  15.  Riches G, Tarasuk V. Canada: Thirty years of food charity and public policy neglect. In: Riches G, Silvasti T, editors. First world hunger revisited: food charity or the right to food. 2nd ed. New York (NY): Palgrave Macmillan; 2014. p. 42–56.  16.  Collins PA, Power EM, Little MH. Municipal-level responses to household food insecurity in Canada: a call for critical, evaluative research. Can J Public Health. 2014;105(2):138–41.  17.  Tarasuk V, Dachner N, Hamelin A-M, Ostry A, Williams P, Bosckei E, et al. A survey of food bank operations in five Canadian cities. BMC Public Health. 2014;14:1234.  18.  Bocskei E, Ostry A. Charitable food programs in Victoria, BC. Can J Diet Pract Res. 2010;71(1):46–8.  19.  Tarasuk V. A critical examination of community-based responses to household food insecurity in Canada. Health Education & Behaviour. 2001;28(4):487–99.  20.  Food Banks Canada. Hunger count 2015: a comprehensive report on hunger and food bank use in Canada [Internet]. Mississauga (ON): Food Banks Canada; 2015. Available from: https://www.foodbankscanada.ca/Hunger-in-Canada/Research.aspx 21.  Kicinski L. Characteristics of short and long-term food pantry users. Michigan Sociol Rev. 2012;26(1):58–74.  22.  Daponte B, Lewis G, Sanders S, Taylor L. Food pantry use among low-income households in Allegheny County, Pennsylvania. J Nutr Educ. 1998;30(1):50–7.  23.  Starkey LJ, Kuhnlein H V, Gray-Donald K. Food bank users: sociodemographic and nutritional characteristics. CMAJ. 1998;158(9):1143–9.  24.  Tarasuk V, Beaton G. Household food insecurity and hunger among families using food banks. Can J Public Health. 1999;90(2):109–13.    91 25.  Robaina KA, Martin KS. Food insecurity, poor diet quality, and obesity among food pantry participants in Hartford, CT. J Nutr Educ Behav. 2013;45(2):159–64.  26.  Hamelin A-M, Mercier C, Bédard A. Discrepancies in households and other stakeholders viewpoints on the food security experience: a gap to address. Health Educ Res. 2010;25(3):401–12.  27.  Tarasuk V, Eakin JM. Charitable food assistance as symbolic gesture: an ethnographic study of food banks in Ontario. Soc Sci Med. 2003;56(7):1505–15.  28.  Loopstra R, Tarasuk V. The relationship between food banks and household food insecurity among low-income Toronto families. Can Public Policy. 2012;38(4):497–514.  29.  Tarasuk V, Dachner N, Loopstra R. Food banks, welfare, and food insecurity in Canada. Br Food J. 2014;116(9):1405–17.  30.  Martin K, Shuckerow M, O’Rourke C, Schmitz A. Changing the conversation about hunger: the process of developing Freshplace. Prog Community Health Partnersh. 2012;6(4):429–34.  31.  The Stop Community Food Centre. The Stop [Internet]. Toronto (ON): The Stop Community Food Centre; 2016 [cited 2016 Sep 10]. Available from: http://thestop.org/ 32.  Food and Agriculture Organization (FAO). The state of food insecurity in the world 2000 [Internet]. Rome: Food and Agriculture Organization of the United Nations; 2000. Report No.: 92-5-104479–1. Available from: http://www.fao.org/docrep/x8200e/x8200e00.htm 33.  Riches G, Silvasti T, editors. First world hunger revisited: food charity or the right to food. 2nd ed. New York (NY): Palgrave Macmillan; 2014.  34.  Anderson SA. Core indicators of nutritional state for difficult-to-sample populations. J Nutr. 1990;120(11):1555–600.  35.  Hamelin A-M, Beaudry M, Habicht J-P. Characterization of household food insecurity in Québec: food and feelings. Soc Sci Med. 2002;54(1):119–32.  36.  Tarasuk V. Discussion paper on household and individual food insecurity [Internet]. Ottawa (ON): Health Canada: Office of Nutrition Policy and Promotion; 2001 [cited 2015 Mar 19]. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/pol/food_sec_entire-sec_aliments_entier-eng.php 37.  Williams PL, MacAulay RB, Anderson BJ, Barro K, Gillis DE, Johnson CP, et al. “I would have never thought that I would be in such a predicament”: voices from women   92 experiencing food insecurity in Nova Scotia, Canada. J Hunger Environ Nutr. 2012;7(2–3):253–70.  38.  Radimer K, Olson C, Campbell C. Development of indicators to assess hunger. J Nutr. 1990;120(Suppl 11):1544–8.  39.  Bush M. Canadian Community Health Survey, Cycle 2.2, Nutrition (2004): Income-related household food security in Canada. [Internet]. Ottawa (ON): Health Canada: Office of Nutrition Policy and Promotion; 2007. Report No.: Cat. H164-42 / 2007E. Available from: http://www.hc-sc.gc.ca/fn-an/surveill/nutrition/commun/income_food_sec-sec_alim-eng.php 40.  Radimer KL, Olson CM, Greene JC, Campbell CC, Habicht J-P, Blumberg SJ, et al. Measurement of household food security in the USA and other industrialised countries. Public Health Nutr. 2002;5(6a):859–64.  41.  Coleman-Jensen A. U.S. food insecurity status: toward a refined definition. Soc Indic Res. 2010;95(2):215–30.  42.  Government of Canada. Benefits [Internet]. Ottawa (ON): Government of Canada; 2016 [cited 2016 Sep 10]. Available from: https://www.canada.ca/en/services/benefits.html 43.  Lightman ES. Social policy in Canada. Don Mills (ON): Oxford University Press; 2003. 294 p.  44.  Dietitians of Canada. Cost of eating in British Columbia 2011 [Internet]. Vancouver (BC): Dietitians of Canada; 2012 [cited 2015 Feb 10]. p. 16. Available from: http://www.dietitians.ca/Dietitians-Views/Food-Security/Household-Food-Insecurity/The-Cost-of-Eating-in-British-Columbia.aspx 45.  Antonishak D, Bennewith E, Hrycuik L, Lutz H, Macdonald J, Raja S, et al. The cost of eating in BC: little money for food the reality for some BC families [Internet]. Vancouver (BC): Dietitians of Canada; 2005 [cited 2016 Jul 19]. p. 19. Available from: https://www.dietitians.ca/Downloads/Public/BC_CostofEating_2005.aspx 46.  Kurrein M, Li C, Rasali D. Food costing in BC 2015 [Internet]. Vancouver (BC): Provincial Health Services Authority (PHSA); 2016. Available from: http://www.phsa.ca/our-services/programs-services/population-public-health/food-security 47.  Food Banks Canada. Hunger count 2014: a comprehensive report on hunger and food bank use in Canada, and recommendations for change [Internet]. Mississauga (ON): Food   93 Banks Canada; 2014 [cited 2015 May 1]. p. 38. Available from: https://www.foodbankscanada.ca/Hunger-in-Canada/Research.aspx 48.  Scharf K, Levkoe C, Saul N. In every community a place for food: the role of the Community Food Centre in building a local, sustainable, and just food system [Internet]. Toronto (ON): Metcalf Food Solutions; 2010 [cited 2016 Oct 5]. p. 51. Available from: http://cfccanada.ca/sites/default/files/documents/In_Every_Community_a_Place_for_Food.pdf 49.  Employment and Social Development Canada. Funding for programs for jobs, training, and social development [Internet]. Government of Canada. 2016 [cited 2016 Jul 19]. Available from: http://www.esdc.gc.ca/en/funding/index.page 50.  Barbolet H. Dig It! A practical toolkit: how local governments can support community gardens [Internet]. Burnaby (BC): Ministry of Community Development & Union of British Columbia Municipalities; 2009 [cited 2016 Jul 19]. Available from: http://www.toolkit.bc.ca/resource/dig-it-community-garden-guide-how-local-governments-can-support-community-gardens 51.  Community Food Centres Canada. Community Food Centres Canada 2015 annual report: donors [Internet]. Toronto (ON); 2015 [cited 2016 Sep 15]. Available from: http://foodcommunitychange.cfccanada.ca/donors 52.  City of Vancouver. Community kitchens [Internet]. Vancouver (BC): City of Vancouver; 2016 [cited 2016 Jul 19]. Available from: http://vancouver.ca/people-programs/community-kitchens.aspx 53.  Hamm MW, Bellows AC. Community food security and nutrition educators. J Nutr Educ Behav. Elsevier; 2003;35(1):37–43.  54.  City of Vancouver. What feeds us: Vancouver food strategy [Internet]. Vancouver (BC): City of Vancouver; 2013 [cited 2015 Apr 29]. p. 145. Available from: http://vancouver.ca/files/cov/vancouver-food-strategy-final.PDF 55.  Riches G. Hunger in Canada: abandoning the right to food. In: Riches G, editor. First world hunger: food security and welfare politics. Toronto (ON): University of Toronto Press; 1997.  56.  Carson EA. Canadian food banks and the depoliticization of food insecurity at the individual and community level. Can Rev Soc Policy. 2014;1(70):7–21.    94 57.  Statistics Canada. Estimates of population, Canada, provinces and territories [Internet]. Ottawa (ON); 2016 [cited 2016 Nov 14]. Report No.: CANSIM-051-0005. Available from: http://www5.statcan.gc.ca/cansim/a47 58.  Downing E, Kennedy S, Fell M. Food banks and food poverty [Internet]. London: House of Commons Library; 2014 [cited 2015 May 19]. p. 29. Available from: http://www.parliament.uk/briefing-papers/SN06657/food-banks-and-food-poverty 59.  Weinfield NS, Mills WG, Institute U, Borger C, Gearing WM, Macaluso T, et al. Hunger in America 2014: a report on charitable food distribution in the United States in 2013 [Internet]. Chicago (IL): Feeding America; 2014 [cited 2016 Oct 5]. Available from: http://www.feedingamerica.org/hunger-in-america/our-research/hunger-in-america/ 60.  Van der Horst H, Pascucci S, Bol W. The “dark side” of food banks? Exploring emotional responses of food bank receivers in the Netherlands. Br Food J. 2014;116(9):1506–20.  61.  Tweedle A, Battle K, Torjman S. Welfare in Canada 2013 [Internet]. Ottawa (ON): The Caledon Institute of Social Policy; 2014 [cited 2016 Sep 16]. p. 93. Available from: http://deslibris.ca.ezproxy.library.ubc.ca/ID/244722 62.  BC Stats. Population projections, British Columbia [Internet]. Vancouver (BC): Government of British Columbia; 2016 [cited 2016 Aug 17]. Available from: http://www.bcstats.gov.bc.ca/StatisticsBySubject/Demography/PopulationProjections.aspx 63.  Holben DH. Food bank users in and around the lower mainland of British Columbia, Canada are characterized by food insecurity and poor produce intake. J Hunger Environ Nutr. 2012;7(4):449–58.  64.  Statistics Canada. Population of census metropolitan areas [Internet]. Ottawa (ON): Government of Canada; 2016 [cited 2016 May 10]. Report No.: 051–0056. Available from: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo05a-eng.htm 65.  Lee DS, Chiu M, Manuel DG, Tu K, Wang X, Austin PC, et al. Trends in risk factors for cardiovascular disease in Canada: temporal, socio-demographic and geographic factors. Can Med Assoc J. 2009;181(3–4):E55-66.  66.  Seligman H, Bolger A, Guzman D, Lopez A, Bibbins-Domingo K. Exhaustion of food budgets at month’s end and hospital admissions for hypoglycemia. Health Affairs. 2014;33(1):116–23.    95 67.  Tarasuk V, Mitchell A, McLaren L, McIntyre L. Chronic physical and mental health conditions among adults may increase vulnerability to household food insecurity. J Nutr. 2013;143(11):1785–93.  68.  Kirkpatrick S, Tarasuk V. Food insecurity and participation in community food programs among low-income Toronto families. Can J Public Health. 2009;100(2):135–9.  69.  Hill RW, Holben DH. Food insecurity is associated with poor social capital, perceived health, and perceived diet among adult food bank users in and around the lower mainland of British Columbia, Canada. FASEB J. 2012;26(1 Suppl):631–8.  70.  Statistics Canada. Health indicator profile, age-standardized rate, annual estimates, by sex, Canada, provinces and territories [Internet]. Ottawa (ON): Government of Canada; 2012 [cited 2016 Jan 1]. Available from: http://www5.statcan.gc.ca/cansim/a05?lang=eng&id=1050503 71.  Tarasuk V, Beaton G. Women’s dietary intakes in the context of household food insecurity. J Nutr. 1999;129(3):672–9.  72.  Tarasuk V. Household food insecurity with hunger is associated with women’s food intakes, health and household circumstances. J Nutr. 2001;131(1):2670–6.  73.  Roncarolo F, Adam C, Bisset S, Potvin L. Traditional and alternative community food security interventions in Montréal, Québec: different practices, different people. J Community Health. 2015;40(2):199–207.  74.  Roncarolo F, Bisset S, Potvin L. Short-term effects of traditional and alternative community interventions to address food insecurity. PLoS One. 2016;11(3):e0150250.  75.  Food Banks Canada. Hunger count 2013: a comprehensive report on hunger and food bank use in Canada, and recommendations for change [Internet]. Mississauga (ON): Food Banks Canada; 2013. p. 40. Available from: https://www.foodbankscanada.ca 76.  Jessri M, Abedi A, Wong A, Eslamian G. Nutritional quality and price of food hampers distributed by a campus food bank: a Canadian experience. J Heal Popul Nutr. 2014;32(2):287–300.  77.  Irwin J, Ng V, Rush T, Nguyen C, He M. Can food banks sustain nutrient requirements? A case study in southwestern Ontario. Can J Public Health. 2007;98(1):17–20.  78.  Tarasuk V, Eakin J. Food assistance through “surplus” food: insights from an ethnographic study of food bank work. Agric Human Values. 2005;22(2):177–86.    96 79.  Loopstra R, Tarasuk V, Bocskei EM, Ostry AS, Emery JCH, Fleisch VC, et al. Food bank usage is a poor indicator of food insecurity: insights from Canada. Soc Policy Soc. 2015;14(3):443–55.  80.  Saul N, Curtis A. The Stop: How the fight for good food transformed a community and inspired a movement. Toronto: Melville House; 2013. 299 p.  81.  The Stop Community Food Centre. 2011 annual program survey [Internet]. Toronto (ON): The Stop Community Food Centre; 2011 [cited 2015 Apr 30]. p. 11. Available from: http://thepod.cfccanada.ca/sites/thepod.cfccanada.ca/files/The Stop Annual Program Survey Summary 2011.pdf 82.  Martin KS, Wu R, Wolff M, Colantonio AG, Grady J. A novel food pantry program: food security, self-sufficiency, and diet-quality outcomes. Am J Prev Med. 2013;45(5):569–75.  83.  MacRae R, Hill S, Bentley A. Policies, programs, and regulations to support the transition to sustainable agriculture in Canada. Am J Altern Agric. 1990;5(2):76–92.  84.  Toronto Food Policy Council. Reducing urban hunger in Ontario: policy responses to support the transition from charity to local food security. Toronto (ON): Toronto Food Policy Council; 1994. p. 36.  85.  The Community Nutritionists Council of BC. Making the connection - food security and public health [Internet]. Vernon (BC); 2004 [cited 2015 Apr 22]. Available from: http://www.phabc.org/pdf/Food_Security.pdf 86.  Kalina L. Building food security in Canada  : a community guide for action on hunger [Internet]. Kamloops (BC): Kamloops FoodShare; 1993. 78 p. Available from: http://www.torontopubliclibrary.ca/detail.jsp?Entt=RDM1854192&R=1854192 87.  Greater Vancouver Food Bank. About us [Internet]. Vancouver (BC): Greater Vancouver Food Bank; 2016 [cited 2016 Jul 18]. Available from: https://www.foodbank.bc.ca/about-us/ 88.  Pelletier D. Advanced training in food and nutrition: disciplinary, interdisciplinary and problem-oriented approaches. Food Nutr Bull. 1997;18:134–45.  89.  Minkler M, Wallerstein N, editors. Community-based participatory research for health: from process to outcomes. 2nd ed. San Francisco (CA): Jossey-Bass; 2011. 546 p.  90.  Strand K, Marullo S, Cutforth N, Stoecker R, Donohue P. Principles of best practice for community-based research. Michigan J Community Serv Learn. 2003;9(3):5–15.    97 91.  Guta A, Roche B. Community-based research. In: Coghlan D, Brydon-Miller M, editors. The SAGE encyclopedia of action research. London: SAGE Publications; 2014. p. 157–9.  92.  Creswell JW. Designing and conducting mixed methods research. 2nd editio. Plano Clark VL, editor. Thousand Oaks (CA): SAGE Publications; 2011.  93.  Krathwohl DR. Methods of education and social science research: an integrated approach. 2nd ed. Long Grove (IL): Waveland Press; 2004.  94.  Mertens DM. Transformative mixed methods research. Qual Inq. 2010;16(6):469–74.  95.  Sweetman D, Badiee M, Creswell JW. Use of the transformative framework in mixed methods studies. Qual Inq. 2010;16(6):441–54.  96.  Azurdia AX, Lecompte E, Sibbald E. Bon appétit! A process evaluation of a campus-based food bank. J Hunger Environ Nutr. 2011;6(3):324–42.  97.  Plano Clark V, Badiee M. Research questions in mixed methods research. In: Tashakkori A, Teddlie C, editors. Handbook of mixed methods in social & behavioural research. Thousand Oaks (CA): SAGE Publications; 2010. p. 275–304.  98.  Seligman H, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304–10.  99.  Li N, Dachner N, Tarasuk V, Zhang R, Kurrein M, Harris T, et al. Priority health equity indicators for British Columbia: household food insecurity indicator report [Internet]. Research to identify policy options to reduce food insecurity (PROOF). Toronto (ON): Provincial Health Services Authority; 2016 [cited 2016 Sep 2]. Available from: http://proof.utoronto.ca/ 100.  Babbie E. The practice of social research. 12th ed. Belmont (CA): Wadsworth Cengage Learning; 2010. 592 p.  101.  Statistics Canada. National Household Survey (NHS) [Internet]. Ottawa (ON): Statistics Canada; 2013 [cited 2015 Feb 16]. Report No.: 5178. Available from: http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5178 102.  Statistics Canada. The General Social Survey: an overview [Internet]. Ottawa (ON): Statistics Canada; 2015 [cited 2015 Feb 16]. Report No.: 89F0115X. Available from: http://www.statcan.gc.ca/pub/89f0115x/89f0115x2013001-eng.htm#a1 103.  Government of British Columbia. Income Assistance Rate Table [Internet]. 2007 [cited 2015 Feb 11]. Available from: http://www2.gov.bc.ca/gov/content/governments/policies-  98 for-government/bcea-policy-and-procedure-manual/bc-employment-and-assistance-rate-tables/income-assistance-rate-table 104.  Statistics Canada. Low income cut-offs, after tax [Internet]. Ottawa (ON): Statistics Canada; 2016 [cited 2016 Sep 9]. Available from: http://www.statcan.gc.ca/pub/75f0002m/2015002/tbl/tbl01-eng.htm 105.  University of British Columbia Information Technology. UBC survey tool [Internet]. Vancouver (BC): University of British Columbia; 2015 [cited 2016 Jul 13]. Available from: https://it.ubc.ca/services/teaching-learning-tools/survey-tool 106.  McCosker H, Barnard A, Gerber R. Undertaking sensitive research: issues and strategies for meeting the safety needs of all participants. Forum Qual Soc Res. 2001;2(1):22.  107.  Smoyer AB, Rosenberg A, Blankenship KM. Setting the stage: creating study sites that promote the safety and dignity of research participants. Soc Work Res. 2014;38(3):178–83.  108.  Corder G, Foreman D. Tests for nominal scale data: chi-square and Fisher exact tests. Nonparametric statistics: a step-by-step approach. 2nd ed. Hoboken (NJ): John Wiley & sons; 2009. p. 172–201.  109.  Statistics Canada. Income research paper series [Internet]. Ottawa (ON): Statistics Canada; 2015 [cited 2016 Jun 5]. Report No.: 75F0002M. Available from: http://www.statcan.gc.ca/pub/75f0002m/75f0002m2015002-eng.htm 110.  Service Canada. Income assistance [Internet]. Government of Canada. Ottawa (ON); 2014 [cited 2016 Jul 16]. Available from: http://www.servicecanada.gc.ca/eng/subjects/benefits//index.shtml 111.  Government of British Columbia. Person with disabilities designation and application: province of British Columbia [Internet]. Victoria (BC): Government of British Columbia; [cited 2016 Sep 8]. Available from: http://www2.gov.bc.ca/gov/content/governments/policies-for-government/bcea-policy-and-procedure-manual/pwd-designation-and-application/designation-application 112.  Government of British Columbia. Family and social supports [Internet]. Victoria (BC): Government of British Columbia; [cited 2016 Jul 17]. Available from: http://www2.gov.bc.ca/gov/content/family-social-supports 113.  McIntyre L, Dutton DJ, Kwok C, Emery JCH. Reduction of food insecurity among low-  99 income Canadian seniors as a likely impact of a guaranteed annual income. Can Public Policy. 2016;42(3):274–86.  114.  Statistics Canada. Focus on geography series, 2011 census: province of British Columbia [Internet]. Ottawa (ON): Statistics Canada; 2012 [cited 2016 Jul 30]. Report No.: 98–314–XWE2011004. Available from: http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-pr-eng.cfm?Lang=Eng&GC=59 115.  Stapleton J, Bednar V. Trading places: Single adults replace lone parents as the new face of social assistance in Canada [Internet]. Toronto (ON): Mowat Centre for Policy Innovation; 2011 [cited 2016 Sep 7]. p. 28. Available from: http://www.mowateitaskforce.ca/sites/default/files/Stapleton.pdf 116.  Christner A, Sterling H. Emergency food provision by nonprofit and religious organizations: a call to study users and nonusers of food pantry services. Society for the Study of Social Problems. New York (NY); 1986.  117.  Nyswander D. Education for health: some principles and their application. Calif Heal. 1956;14:65–70.  118.  O’Connor C, Gheoldus M, Jan O. Comparative study on EU member states’ legislation and practices on food donation: final report [Internet]. Brussels (BEL): European Economic and Social Committee (EESC); 2014 [cited 2016 Sep 27]. p. 78. Available from: http://www.eesc.europa.eu/resources/docs/comparative-study-on-eu-member-states-legislation-and-practices-on-food-donation_finalreport_010714.pdf 119.  Ontario Ministry of Finance. Community food program donation tax credit [Internet]. Government of Ontario; 2014 [cited 2016 Sep 27]. Available from: http://www.fin.gov.on.ca/en/credit/cfpdtc/ 120.  Kirkpatrick S, Tarasuk V. The relationship between low income and household food expenditure patterns in Canada. Public Health Nutr. 2003;6(6):589–97.  121.  Bazerghi C, McKay FH, Dunn M. The role of food banks in addressing food insecurity: a systematic review. J Community Health. 2016;41(4):732–40.  122.  Campbell E, Hudson H, Webb K, Crawford PB. Food preferences of users of the emergency food system. J Hunger Environ Nutr. 2011;6(2):179–87.  123.  Canadian Food Inspection Agency. Date labelling on pre-packaged foods [Internet]. Government of Canada. 2014. Available from:   100 http://www.inspection.gc.ca/food/information-for-consumers/fact-sheets-and-infographics/date-labelling/eng/1332357469487/1332357545633 124.  Operation Sharing. Foods for friends [Internet]. Operation Sharing; 2015 [cited 2016 Aug 25]. Available from: http://operationsharing.com/foods-for-friends/ 125.  Fry D, Zask A. Applying the Ottawa Charter to inform health promotion programme design. Health Promot Int. 2016;daw022.  126.  Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304–10.  127.  Bloch P, Toft U, Reinbach HC, Clausen LT, Mikkelsen BE, Poulsen K, et al. Revitalizing the setting approach: supersettings for sustainable impact in community health promotion. Int J Behav Nutr Phys Act. 2014;11(1):118.  128.  Knoblock-Hahn A, Murphy A, Brown K, Medrow L. Integrative nutrition and health models targeting low-income populations: a pilot intervention in three food banks. J Acad Nutr Diet. 2016;  129.  National Council of Welfare. Welfare incomes 2009 [Internet]. Ottawa (ON): National Council of Welfare; 2010. Report No.: HS51-1/2009E-PDF. Available from: http://ywcacanada.ca/data/research_docs/00000179.pdf 130.  Canada Mortgage and Housing Corporation (CMHC). CHS rental market survey 2015 [Internet]. Ottawa (ON): CMHC; 2015. Report No.: 64683. Available from: https://www03.cmhc-schl.gc.ca/catalog/productDetail.cfm?lang=en&cat=55&itm=2&fr=1473688242460 131.  McLaughlin C, Tarasuk V, Kreiger N. An examination of at-home food preparation activity among low-income, food-insecure women. J Am Diet Assoc. 2003;103(11):1506–12.  132.  Power E, Abercrombie D, St-Germain A-A, Vanderkooy P. Addressing household food insecurity in Canada: position statement and recommendations from Dietitians of Canada [Internet]. 2016 [cited 2017 Jan 9]. Available from: www.dietitians.ca/foodinsecurity 133.  The Stop Community Food Centre. Community action program [Internet]. 2016 [cited 2016 Nov 10]. Available from: http://thestop.org/programs/build-hope/community-action-program/    101 Appendices Appendix A  Food bank site profiles  Neighbourhood Site size (number range weekly users) Survey site    A Downtown Medium (155-220)  B Hastings Sunrise Small (<155)  C Burnaby Central Large (>220) Focus group site    A Downtown Medium (155  - 220)  B Hastings Sunrise Small (<155)  C Burnaby Central Large (>220)  D West End Medium (155  - 220)  E  Lonsdale Small (<155)      102 Appendix B  Survey - Food insecurity in Greater Vancouver: community consultation with food bank members 	  The Greater Vancouver Food Bank has teamed up with UBC and SFU to learn more about their member's experiences using food banks, and the needs and challenges of their everyday lives. We want to find out more about what food banks can do to improve the services they provide, such as where to place locations, and what types of food to offer.   I will be asking you some questions today, and I would like to confirm that you know that:  1. Your responses to this survey are confidential, and no personal information about you will be shared. 2. This information will not be used to determine whether you are eligible to receive food from the food bank. 3. There are no wrong answers to the questions, and your honest responses are what we are looking for.  4. You can choose not to answer any question, or stop the survey at any time. Do you have any questions for me before we begin?     Module 1: We are interested in learning about how members get to and from the food bank. Q 1.1a: How did you get to the food bank today? Interviewer! Do not read out response options, but probe to get more information as needed. Record the mode of transportation that covered the largest distance. ! Car (owned by respondent) ! Car (borrowed from a friend or relative) ! Car sharing program (Car2go, Moto Car, Evo) ! Public transport (Bus/ Sky Train/ Sea Bus/ Handy Dart) (proceed to Q 1.1b.) ! Bicycle ! Skateboard, rollerblades  ! Motorized scooter or wheelchair ! Walking ! Other, please specify... ______________________ ! (Prefer not to answer)  If participant used public transportation - please ask Q1.1b Q 1.1b: Which bus routes, sky train lines, or other types of public transportation did you use? Please be as specific as possible, including all types (bus, sky train, sea bus, handydart), your start destination, and where you got off. Interviewer! Probe for bus numbers or Skytrain line stops _________________________________________________________     103 Module 2: We would like to learn more about your experiences using food banks. For each of the following statements, please indicate if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree. I have a piece of paper with these responses here - please indicate where you stand on these statements. Interviewer! Use sheet for participant to point to their answer for Q2.1 – 2.9. ! Strongly agree ! Agree ! Neither agree nor disagree ! Disagree ! Strongly disagree ! (Prefer not to answer)  Q 2.1. Your overall experience at the food bank has been positive. Do you... Q 2.2. You feel physically safe while at the food bank. Do you... Q 2.3. You feel respected by the food bank volunteers at this location. Do you... Q 2.4. You feel respected by other food bank members. Do you...   Q 2.5. You know how to access other community resources, such as community centres and social assistance agencies. Do you... Q 2.6. By attending this food bank location, you have found out about other community services. Do you... Q 2.7. You would like other community services to be available at the food bank. For example, library services, public health nurses, dietitians, legal advocacy groups, or tax assistance groups.  Do you... Q 2.8. You would like other food bank members to help you sign up for other community services. For example accessing the library, health care, or legal advocacy. Do you... Q 2.9. You have knowledge that you could share, that other food bank members could benefit from. Do you... Interviewer Prompt: Do you have knowledge or skills that could help other food bank members?  INTERVIEWER! If respondent indicated Strongly Agree or Agree to Q2.9 - please ask: What knowledge or skills can you share that could help other food bank members?   Please specify…_______________________________  Q 2.10. How do you access information about the Food Bank? INTERVIEWER: Select all that apply. o At this food bank location - Posters o At this food bank location - Volunteers/staff o Other food bank members o In person at the Head Office o Internet/website o Telephone   104 o Email o Friends/family o BC 211 o Other, please specify... ______________________ o (Prefer not to answer)  Q 2.11. Since you began coming to the Food Bank, has your experience with hunger decreased, increased, or stayed about the same? ! Decreased ! Increased ! Stayed about the same ! Don't know ! (Prefer not to answer)  INTERVIEWER! If Participant reports hunger has INCREASED please read the following:  Q 2.11b. Why do you think your hunger has increased since you began coming to the food bank?   _____________________________  Q 2.12. Thinking about the food that you received the last time you were at the Food Bank, how many days did this food last?  Number of days INTERVIEWER: Note additional comments about response if provided by participant ! <1 day ! 1 ! 2 ! 3 ! 4 ! 5 ! 6 ! 7 ! >7  Notes:  Q 2.13. Does the Food Bank provide you with enough additional food each month to meet the food needs of your household? INTEVIEWER! Clarify if participant is unsure: Given the amount of food you can afford to buy each month, does the food bank offer enough additional food to meet your household's food needs? ! Yes   105 ! No ! Sometimes ! Don't know ! (Prefer not to answer)  Q 2.14. What foods would you like to receive from the Food Bank? Please list all of the foods you would like to receive. INTERVIEWER! Check all boxes that apply, and indicate specific preferences and/or additional comments if given. o Fruits and vegetables, please specify... ______________________ o Meat and alternatives, please specify... ______________________ o Dairy and alternatives, please specify... ______________________ o Grain products, please specify... ______________________ o Other food items, please specify... ______________________ o Other non-food items, please specify... ______________________  Q 2.15. How long have you been using the Food Bank? Interviewer: Prompt if the participant is unsure. "That is, how long has it been since you first signed up as a member at the food bank." ! Less than 6 months  ! 6 - 11 months  ! 1 - 5 years ! More than 5 years ! (Prefer not to answer)  Q 2.16. How many times have you used a food bank in the last 3 months?   ____________  Q. 2.17. Do you think that you will be coming to the Food Bank 3 months from today? ! Yes  ! No  ! Other response, please specify... ______________________ ! Don't know ! (Prefer not to answer)       106 Module 3: We would like to find out a bit more about how you access and prepare food.  Q 3.1 Do you have access to:      Yes No (Prefer not to answer) a) A working stove or hot plate    ▢     b) A microwave          c) A working refrigerator          d) A working freezer        e) An area to store food         Q 3.2. How would you rate your cooking skills? Would you say they are... Interviewer! Read out response options. ! Excellent ! Good ! Average ! Fair ! Poor ! (Prefer not to answer) Q 3.3. Do you have any food allergies, dietary restrictions, or dental concerns that prevent you from eating particular foods? ! Yes - Could you please specify what those food allergies, dietary restrictions, or dental concerns are...  ! No ! (Prefer not to answer) Q. 3.4. Now I am going to read you a list of places where people buy or obtain food. For each of the places could you tell me if you got food there for yourself, or other household members, during the past month:        Yes    No          Don’t know  (Prefer not to answer) a) Grocery store, market, or deli          b) Quest Food Exchange          c) Restaurant               - full service, where you are seated and served    d) Cafeteria, food court, or fast food restaurant         e) From a friend or family member             - who you don't live with    f) Free community meal programs             – e.g. soup kitchen, meal line  g) Low cost community meal programs            - e.g. low price meal at a community centre    h) School breakfast or lunch program         i) Community kitchen or cooking program        j) Garden - community garden, home garden             107 Q 3.4b. Are there any other places we didn't mention where you got food from in the past month? ! Yes - please specify these other places... ______________________ ! No ! (Prefer not to answer) Notes:    Module 4: We are interested in learning more about where food bank members live and who they live with, so I will be asking you a few questions about your home and household members.  Q 4.1. In what type of dwelling do you currently live? Interviewer! Do not read out response options. ! Apartment ! Basement suite ! Partially detached home (duplex, townhouse) ! Detached home ! Rooming house (single room occupancy, hotel) ! Shelter  ! Vehicle - Car/van/motorhome (skip to Q4.4) ! Homeless/no fixed address (skip to Q4.4) ! Other, please specify... ______________________ ! (Prefer not to answer) Q 4.2. Do you own this dwelling, even if it is still currently being paid for through a mortgage or loan? ! Yes ! No ! Don't Know ! (Prefer not to answer) Q 4.3. How much money do you pay in rent or mortgage every month? I have a list of ranges here - please indicate the range that your monthly rent or mortgage falls into. ! A) $ 0 - 500 ! B) $ 501 - 1000 ! C) $ 1001 - 1500 ! D) $ 1501 - 2000 ! E) Greater than $2000 ! F) Don't know ! (Prefer not to answer)      108 Q 4.4. Can you recall your postal code? Interviewer! If member does not have a fixed address or doesn't know their postal code please probe for the closest cross street or neighbourhood where they usually reside. Postal Code  _________________________   If postal code unknown, nearest cross street or neighbourhood    Q 4.5. Including yourself, how many people do you currently live with? Interviewer! Do not read out response options. If participant is unsure, probe by asking "how many people do you currently live with who you also share your food with." ! 1 (skip to Q5.1) ! 2 ! 3 ! 4 ! 5 ! 6 ! 7 ! If more than 7, please specify... ______________________ ! (Prefer not to answer) !  INTERVIEWER! Only ask 4.6 if the participant indicated they lived with others. Q 4.6. What is your relationship to the other individual(s) that you live with, as well as their age(s) and gender(s).  Gender   Relationship to Participant  Age   !  Male    ______________________________   _____________   ! Female ! Transgender ! Other ! Prefer not to answer Person 1 Gender selection   ______________________________  _____________ Person 2 Gender selection   ______________________________  _____________    Person 3 Gender selection   ______________________________  _____________      Person 4 Gender selection   ______________________________  _____________    Person 5  Gender selection  ______________________________  _____________    Person 6 Gender selection   ______________________________  _____________     Person 7 Gender selection  ______________________________  _____________     109 Module 5: We would like to learn more about the financial experiences of food bank members, and now I will ask you some questions about the income in your household. I want to remind you that all of the information you provide will remain completely confidential.   Q 5.1a. Are you currently employed in a job or business where you receive pay for your work? ! Yes ! No  (skip to Q5.2) ! Prefer not to answer (skip to Q5.2) Q 5.1b. How many jobs are you currently working at? ! 1 ! 2 ! 3 ! 4 ! 5 or more Q 5.1c. During the last week, how many hours did you work at your job(s) or business? Please enter the total number of hours worked for pay at all jobs held during the past week. ! ______________ ! Don't know Q 5.1d. What is the hourly wage range of your employment?  I have a list of ranges here - please point to the range that your hourly-wage falls into. Interviewer! If they had more than one job, enter the wage range of their best-paid job. ! Less than or equal to $10.25 per hour ! $10.26 - $14.99 per hour ! $15.00 or more per hour ! Prefer not to answer Notes: Q 5.2. I am going to read out a list of different sources of income. Please indicate whether you, or other members of your household, receive income from these sources. Does your household currently receive income from..      Yes     No       Don’t know    (Prefer not to answer) a) Wages from jobs or employment           b) Employment Insurance or EI           c) Disability Benefits            d) Social Assistance Benefits           e) Canadian Pension Plan or CPP           f) Rent from others living in your home            110 INTERVIEWER! If the participant has indicated there are children under 18 years old in the house...Does your household currently receive income from... Yes     No       Don’t know    (Prefer not to answer) f) Child Tax Benefit            g) Child Support Payments           5.2b. Are there any other sources of income that your household receives? ! Yes - What are these other sources of income... ______________________ ! No ! Don't know  ! (Prefer not to answer) Q 5.3. Thinking of all sources of income, what was the total monthly income of your household in the past month? I have a list of ranges here - please point to the range that your household monthly income falls into. ! A) $0 - $599 ($0 - 7,199/year) ! B) $600 - $1199 ($7,200 - 14,399/year) ! C) $1200 - $1799 ($14,400 - 21,599/year) ! D) $1800 - $2399 ($21,600 - 28,799/year) ! E) $2400 or greater (>$28,800) ! F) Don't know  ! G) (Prefer not to answer) Q 5.4 Do you currently work in a position where you are not paid for your time. I will read some examples below - please indicate if you do the following...  Interviewer! Select all that apply. o Volunteer at the food bank o Volunteer with any other organization or group o Caregiving for children  o Caregiving for adults o Other, please specify... ______________________ o None of the above o (Prefer not to answer) INTERVIEWER! Do not read out loud. We are now moving to the food security module. Does this participant live alone?  Please select yes or no below to indicate which version of the module the participant will receive.  ! Yes (survey will automatically skip to page 18) ! No (survey will move to page 13)    111 Module 6: The following questions are about the food situation for your household in the past 12 months.   Q 6.1. Which of the following statements best describes the food eaten by your household in the past 12 months? That is since July/August/September of last year Interviewer! Read out response options. ! A) You and other household members always had enough of the kinds of foods you wanted to eat ! B) You and other household members had enough to eat, but not always the kinds of foods you wanted ! C) Sometimes you and other household members did not have enough to eat ! D) Often you and other household members did not have enough to eat ! E) Don't know ! (Prefer not to answer)  Now I'm going to read you several statements that may be used to describe the food situation for a household. Please tell me if the statement was often true, sometimes true, or never true for you and other household members in the past 12 months.  Q 6.2. The first statement is: You and other household members worried that food would run out before you got money to buy more. Was that often true, sometimes true, or never true in the past 12 months? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) Q 6.3. The food that you and other household members bought just didn't last, and there wasn't any money to get more. Was this often true, sometimes true, or never true in the past 12 months? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) Q 6.4. You and other household members couldn't afford to eat balanced meals. Was this often true, sometimes true, or never true in the past 12 months? Interviewer! If participant asks about a balanced meal, just say - "whatever your idea of a balanced meal is." ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) INTERVIEWER! DO NOT READ OUT LOUD. Has this participant stated that they live with children? If you are unsure - ask if there are children under 18 in the household. IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q 6.5 and 6.6; OTHERWISE SKIP TO NEXT PAGE    112 Q 6.5. Now I'm going to read a few statements that may describe the food situation for households with children. You or other adults in your household relied on only a few kinds of food to feed the child(ren) because you were running out of money to buy food. Was that often true, sometimes true, or never true in the past 12 months? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) Q 6.6. You or other adults in your household couldn't feed the child(ren) a balanced meal because you couldn't afford it. Was that often true, sometimes true, or never true in the past 12 months? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) Notes:    INTERVIEWER! DO NOT READ OUT LOUD. First Level Screen If affirmative response to "often true" or "sometimes true" to any Q 6.2 - 6.6, or if responded to Q 6.1 with 3 or 4 (sometimes or often did not have enough to eat) then click yes to continue to stage 2. ! Yes (survey will proceed to stage 2) ! No  (survey will automatically skip to Module 7 - page 23) Stage Two - Questions 6.7 - 6.11 Ask households passing the First Level Screen INTERVIEWER! DO NOT READ OUT LOUD.IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q 6.7; OTHERWISE SKIP TO Q 6.8a  Q 6.7. The children were not eating enough because you and other adult members of the household couldn't afford enough food. Was that often, sometimes, or never true in the past 12 months? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) The following few questions are about the food situation in the past 12 months for you or any other adults in your household.     113 Q 6.8a. In the past 12 months, since last July/August/September, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food? ! Yes ! No (skip to Q6.9) ! (Prefer not to answer) INTERVIEWER: IF YESQ 6.8b. How often did this happen? Would you say... ! Almost every month ! Some months, but not every month ! Only 1 or 2 months ! (Prefer not to answer) Q 6.9. In the past 12 months, did you personally ever eat less than you felt you should because there wasn't enough money to buy food? ! Yes ! No ! (Prefer not to answer) Q 6.10. In the past 12 months, were you personally ever hungry but didn't eat because you couldn't afford enough food? ! Yes ! No ! (Prefer not to answer) Q 6.11. In the past 12 months, did you personally lose weight because you didn't have enough money for food? ! Yes ! No ! (Prefer not to answer) Notes:    INTERVIEWER! DO NOT READ OUT LOUD. Second Level Screen If affirmative response to any Q6.7 - 6.11 click yes to continue to stage 3. If not select no to skip to Module 7 ! Yes (survey will proceed to stage 3) ! No (Survey will automatically skip to Module 7 - page 23) Stage Three - Questions 6.12 - 6.16 Ask households passing the Second Level Screen      114 Q 6.12. In the past 12 months, did you or other adults in your household ever not eat for a whole day because there wasn't enough money for food? ! Yes  ! No  ! (Prefer not to answer)  INTERVIEWER: IF YESQ 6.12b. How often did this happen? Would you say... ! Almost every month ! Some months, but not every month ! Only 1 or 2 months  ! (prefer not to answer) INTERVIEWER! DO NOT READ OUT LOUD.IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q 6.13 - 6.16; OTHERWISE MODULE 6 COMPLETE - Click SKIP TO MODULE 7 ! Skip to Module 7 (page 23)  Now, a few questions on the food experiences for children in your household. Q 6.13. In the past 12 months, did you or other adults in your household ever cut the size of any of the children's meals because there wasn't enough money for food? ! Yes ! No ! (Prefer not to answer) Q 6.14a. In the past 12 months, did any of the children ever skip meals because there wasn't enough money for food?  ! Yes ! No ! (Prefer not to answer) INTERVIEWER: IF YESQ 6.14b. How often did this happen? Would you say... ! Almost every month ! Some months, but not every month ! Only 1 or 2 months ! (Prefer not to answer) Q 6.15. In the past 12 months, were any of the children ever hungry but you just couldn't afford more food? ! Yes ! No ! (Prefer not to answer)     115 Q 6.16. In the past 12 months, did any of the children ever not eat for a whole day because there wasn't enough money for food? ! Yes ! No ! (Prefer not to answer) INTERVIEWER! DO NOT READ OUT LOUD. Module 6 is complete - Click SKIP TO MODULE 7 ! Skip to Module 7 (page 23)  Module 6: The following questions are about your food situation in the past 12 months.  Q 6.1. Which of the following statements best describes the food you have eaten in the past 12 months? That is since July/August/September of last year. Would you say... ! A) You always had enough of the kinds of foods you wanted to eat ! B) You had enough to eat, but not always the kinds of foods you wanted ! C) Sometimes you did not have enough to eat ! D) Often you did not have enough to eat ! E) Don't know ! (Prefer not to answer) Now I'm going to read you several statements that may be used to describe the food situation for a household. Please tell me if the statement was often true, sometimes true, or never true for you in the past 12 months. Q 6.2. The first statement is: You worried that food would run out before you got money to buy more. Was that often true, sometimes true, or never true in the past 12 months? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) Q 6.3. The food that you bought just didn't last, and there wasn't any money to get more. Was that often true, sometimes true, or never true in the past 12 months?  ! Often true ! Sometimes true ! Never true ! (Prefer not to answer) Q 6.4. You couldn't afford to eat balanced meals. In the past 12 months was that often true, sometimes true, or never true? ! Often true ! Sometimes true ! Never true ! (Prefer not to answer)   116 INTERVIEWER! DO NOT READ OUT LOUD. First Level Screen If affirmative response to "often true" or "sometimes true" to any Q 6.2 - 6.4, or if responded to Q 6.1 with 3 or 4 (sometimes or often did not have enough to eat) then click yes to continue to stage 2 ! Yes (survey will proceed to Stage 2) ! No  (survey will automatically skip to Module 7 - page 23)  Stage Two - Questions 6.8 - 6.11 Ask individuals passing the First Level Screen Q 6.8. In the past 12 months, since last July/August/September did you ever cut the size of your meals or skip meals because there wasn't enough money for food? ! Yes  ! No (Go to Q6.9) ! (Prefer not to answer) IF YES! Question 6.8a. How often did this happen? Would you say... ! Almost every month ! Some months but not every month ! Only 1 or 2 months ! (Prefer not to answer) Q 6.9. In the past 12 months, did you ever eat less than you felt you should because there wasn't enough money to buy food? ! Yes ! No ! (Prefer not to answer) Q 6.10. In the past 12 months, were you ever hungry but didn't eat because you couldn't afford enough food? ! Yes ! No ! (Prefer not to answer) Q 6.11. In the past 12 months, did you lose weight because you didn't have enough money for food? ! Yes ! No ! (Prefer not to answer)  INTERVIEWER! DO NOT READ OUT LOUD. Second Level Screen If affirmative response to any Q6.8 - 6.11 click yes to continue to stage 3. If not select no to skip to Module 7 ! Yes (survey will proceed to Stage 3) ! No  (Survey will automatically skip to Module 7 - page 23) Stage Three - Questions 6.12   117 Q 6.12. In the past 12 months, did you ever not eat for a whole day because there wasn't enough money for food? ! Yes ! No (End of Module) ! (Prefer not to answer) INTERVIEWER: IF YES!Q 6.12b. How often did this happen? Would you say... ! Almost every month ! Some months but not every month ! Only 1 or 2 months Q 7.1. The last few questions talked about lack of money as a reason for cutting the size of meals or skipping meals. In the last 3 months, did you cut the size of your meals or skip meals for any other reason(s)?  ! Yes - please specify the stated reason(s)... ______________________ ! No ! (Prefer not to answer)  Module 8: Next, I will be asking you a few questions about yourself.  Q 8.1. What is your age and gender?  Age ___________ Gender        ! Male ! Female ! Transgender ! Other ! Prefer not to answer Q 8.2. People in Canada come from many different backgrounds. How do you define yourself in terms of ethnic, racial, or cultural background? Interviewer! Do not read out response options. If respondent provides more than one answer, ask them which background they primarily identify with. If respondent provides specific answer that is not one of the stated categories - select other and specify response.  ! First Nations/Metis/Inuk ! White/Caucasian ! Chinese ! South Asian ! Black - African ! Black - Caribbean ! Black - Other ! Filipino ! Central American   118 ! South American ! Southeast Asian ! Arab ! West Asian ! Japanese ! Korean ! Other, please specify... ______________________ ! (Prefer not to answer) Q 8.3. Were you born in Canada? ! Yes  (skip to Q 8.4) ! No (read Q 8.3b) ! (Prefer not to answer) Q 8.3b. How many years have you lived in Canada? Interviewer! Do not read out response options. ! <1 year ! 1 - 5 years ! > 5 years ! (prefer not to answer) Q 8.4. What is the highest level of education you have attained? Interviewer! Do not read out response options. ! Less than secondary school diploma or equivalent ! High school diploma or high school equivalency certificate (GED) ! Some college, university, or trade school ! Trade certificate or diploma ! College, CEGEP, or other non university certificate or diploma (other than trades) ! University certificate or diploma below the bachelor level ! Bachelor's degree ! University certificate, diploma, or degree above the bachelor's level ! Other, please specify... ______________________ ! (Prefer not to answer) Q 8.5. Was this education completed in Canada? ! Yes ! No ! (Prefer not to answer) Q 8.6. How would you rate your skill of reading in English? Would you say it is... ! Excellent ! Good   119 ! Average ! Fair ! Poor ! (Prefer not to answer)  Q 8.7. Which languages do you speak at home? Interviewer! Do not read out response options. If participant gives multiple responses select all that apply.  o English o French o Arabic o Cantonese o Farsi o German o Gujarati o Hindi o Italian  o Korean  o Mandarin  o Punjabi  o Russian  o Serbo-croatian  o Spanish  o Tagalog  o Tamil o Other, please specify... ______________________ o (Prefer not to answer) Notes:    Module 9: We want to learn more about the health needs and health concerns of food bank members to find out if there are additional services or community partners that the food bank could connect with in the future. The next set of questions is focused on your access to the medical system and your health. I want to remind you that your responses to these question are confidential and we will not share any personal information about you. Q 9.1. Have you visited a doctor in the last year? ! Yes ! No ! (Prefer not to answer)   120 Q 9.2a. Have you visited a dentist in the last year? ! Yes (skip to Q 9.3) ! No ! (Prefer not to answer)  Q. 9.2b. If NO....What are the reasons that you have not been to a dentist in the past year? o Have not gotten around to it. o Respondent did not think it was necessary o Doctor did not think it was necessary o Personal or family responsibilities o Not available - at time required o Not available - at all in the area o Waiting time was too long o Transportation - problem o Language - problem o Cost o Do not have dental coverage (insurance) o Did not know where to go o Fear (e.g. - painful, embarrassing, find something wrong) o No Teeth or Wears dentures o Unable to leave the house due to a health problem o Other, please specify... ______________________ o (Prefer not to answer) Q 9.3. In general, would you say that your physical health is... ! Excellent ! Very Good ! Good ! Fair ! Poor ! (Prefer not to answer) Q 9.4. In general, would you say that your mental health is... ! Excellent ! Very Good ! Good ! Fair ! Poor ! (Prefer not to answer)   121 We are specifically interested in a few health conditions that we are collecting information about. I am going to read out some health conditions and I would like you to tell me if you have the condition.   Q 9.5. Do you have diabetes? ! Yes ! No ! Don't know ! (Prefer not to answer) Q 9.6. Do you have high blood pressure? ! Yes ! No ! Don't know ! (Prefer not to answer) Q 9.7. Are there any other chronic diseases or health conditions that you have that you would like to share with us? ! Yes, please specify... ______________________ ! No ! (Prefer not to answer) Q 9.8. Have either of your biological parents had a heart attack? ! Yes ! No ! Unsure ! (Prefer not to answer) Q 9.9. We would like to know about your history of smoking. Which of the following best describes your history of tobacco use... ! You have never smoked - (skip to Q 9.10) ! You are a former smoker who last smoked more than 12 months ago - (skip to Q 9.10) ! You are a current smoker or you recently quit in the last 12 months - (please answer Q 9.9b) ! (Prefer not to answer) Q 9.9b. If you are a current smoker or recently quit in the last 12 months please indicate the # of cigarettes you smoke or smoked per day?   ______________ Q 9.10. Over the last 12 months what has been your typical exposure to other people's tobacco smoke? Would you say it is... ! No exposure or less than one hour of secondhand smoke exposure per week ! One or more hours of secondhand smoke exposure per week ! (Prefer not to answer)    122 Q 9.11. How often have you felt work or home-life stress in the last year? Would you say... ! Never  ! Some periods of stress  ! Several periods of stress  ! Permanent or chronic stress ! (Prefer not to answer) Q 9.12. During the last 12 months was there ever a time when you felt sad, blue, or depressed for two weeks or more in a row? ! Yes ! No ! (Prefer not to answer) Q 9.13. How active are you in your spare time? Would you say... Interviewer! Read out the response options. ! You are mainly sedentary  (for example - sitting, reading, or watching television) ! You perform mild exercise requiring minimal effort  (for example - light walking, stretching, yoga) ! You perform moderate exercise ( for example - brisk walking, bicycling)  ! You perform strenuous exercise where your heart beats rapidly (for example - running/jogging, sports, or swimming) ! (Prefer not to answer) These next questions are about the food items you ate or drank during the past 30 days. Please think about all meals, snacks, and food consumed at home and away from home. I will be asking how often you ate or drank each type of food: for example, once a day, twice a week, three times a month, and so forth. Q 9.14. Over the last month, how many times did you eat salty foods or snacks? Examples of salty foods or snacks include pretzels, pickles, salted nuts, potato chips, processed cheese, processed meats (ham, hot dogs etc.), soy sauce, soups, frozen meals and salad dressings. Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?”  ! Never ! 1-3 times in the last month ! 1-2 times per week ! 3-4 times per week ! 5-6 times per week ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer)   123 Q 9.15. Over the last month, how many times did you eat deep fried foods or fast foods? Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?”  !  Never ! 1-3 times in the last month ! 1-2 times per week ! 3-4 times per week ! 5-6 times per week ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer) Q 9.16. Over the last month, how many times  did you eat meat and/or poultry? Count all meat and poultry - fresh, canned, or frozen, but do not include fish. Include meat and poultry you ate at all meal times and for snacks. Interviewer: Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?”  !  Never ! 1-3 times in the last month ! 1-2 times per week ! 3-4 times per week ! 5-6 times per week ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer) Q 9.17. Over the last month, how many times did you eat fish or seafood? Count all fish and seafood- fresh, canned, or frozen.  Include fish and seafood you ate at all meal times and for snacks.  Interviewer: Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?”  !  Never ! 1-3 times in the last month ! 1-2 times per week   124 ! 3-4 times per week ! 5-6 times per week ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer) These next questions are about the fruit you ate or drank during the past 30 days. Include fruit eaten at all meals and snacks. Please think about all forms of fruits - including cooked, fresh, frozen or canned, as well as fruits eaten alone or mixed with other foods.  Q 9.18a. During the past month, how many times did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice. Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?” INTERVIEWER NOTE: 100% pure juice from concentrate (i.e., reconstituted) is counted. Do not include fruit drinks with added sugar or other added sweeteners like Kool-aid, Hi-C, lemonade, cranberry cocktail, Tampico, Sunny Delight, Snapple, Fruitopia, Gatorade, PowerAde, or yogurt drinks. Do not include vegetable juices such as tomato and V8 if respondent provides but include in "vegetables” question.   !  Never - (skip to Q9.19) ! 1-3 times in the last month ! 1-2 times per week ! 3-4 times per week ! 5-6 times per week ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer) Q 9.18b. Each time you drank 100% juice how much did you usually drink? Would you say... ! Less than 3/4 of a cup (less than 6 ounces) ! 3/4 cup to 1-1/4 cup (6-10 ounces) ! 1-1/4 cup to 2 cups (10 - 16 ounces) ! More than 2 cups (more than 16ounces) ! (Prefer not to answer)    125 Q 9.19. During the past month, how many times did you eat fruit?  Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?” Read only if necessary: “Your best guess is fine. Include apples, bananas, applesauce, oranges, grape fruit, fruit salad, watermelon, cantaloupe or musk melon, papaya, lychees, star fruit, pomegranates, mangos, grapes, and berries such as blueberries and strawberries.” !  Never - (skip to Q9.20a) ! 1-3 times in the last month ! 1-2 times per week ! 3-4 times per week ! 5-6 times per week ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer) Q 9.19b. Each time you ate fruit, how much did you usually eat? Would you say... ! Less than one medium fruit or less than 1/2 cup  ! 1 medium fruit or 1/2 cup  ! 2 medium fruits or 1 cup  ! More than 2 medium fruits or more than 2 cups  ! (Prefer not to answer) These next questions are about the vegetables you ate or drank during the past 30 days. Include vegetables eaten at all meals and snacks. Please think about all forms of vegetables including cooked, fresh, frozen, and canned, as well as vegetables eaten alone or mixed with other foods.  Q 9.20a. Over the last month, how many times did you eat vegetables? Give participant sheet to show selection choices. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?” Read only if necessary: “Your best guess is fine. Include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, onions, cabbage, cucumber, and potatoes that are not fried such as baked or mashed potatoes. Include orange- colored vegetables such as sweet potatoes, pumpkin, squash, or carrots, and dark green vegetables like broccoli or dark leafy greens including romaine, chard, kale, collard greens or spinach."  INTERVIEWER NOTE: Do not include products consumed as condiments including ketchup, salsa, chutney, relish. !  Never - (skip to Q10.1) ! 1-3 times in the last month ! 1-2 times per week ! 3-4 times per week ! 5-6 times per week   126 ! 1 time per day ! 2 times per day ! 3 times per day ! 4 times per day ! 5 or more times per day ! (Prefer not to answer) Q 9.20b. Each time you ate vegetables, how much did you usually eat? Would you say... ! Less than 1/2 cup  ! 1/2 cup to 1 cup ! 1 - 2 cups ! More than 2 cups  ! (Prefer not to answer)  Q 10.1. What do you think is the most important thing that the Food Bank should know about its members?    We have now reached the end of our survey. Q 10.2.  Do you have any other comments about the Food Bank, or is there anything else you would like to add that we haven't talked about?    INTERVIEWER NOTE SECTION: Please make note of anything important or unexpected that happened during the survey. Include interesting comments that the participant made that are relevant to our work, but weren't directly asked in the survey.  	  	  	      127 Appendix C  Policy and protocol manual  C.1 Policy 010: Study participant recruitment   Approved by: Principal Investigator  Effective Date: June 5, 2015 Revised: June 30, 2015  Policy Recruitment will be an open and safe process that is free from coercion. All members of the research team will be able to appropriately describe the research process and research goals to food bank members.   Rationale To ensure all participants are able to provide free and informed consent.   Procedure Prior to Recruitment 1. All research team members will be provided with training on the research process and goals.   Initial Recruitment Day: 2. On the initial recruitment day the Peer Research Assistant (PRA) hands out Research Brochures and explains the study to all food bank members as they wait in the line-up or waiting area at the food bank.   3. PRA keeps a tally of the reasons why food bank members do not want to participate on the Study Recruitment Form.   4. If any food bank member displays interest, the PRA will invite them to the recruitment booth on site to meet with the Research Coordinator or a research team member to review consent and go through consent process.  For All Recruitment Days: 5. Research team members will run a “health fair” at the recruitment booth where blood pressure measurements, handgrip strength, height, and weight can be taken.   6. A research member initiates conversation about the study with food bank member as he/ she approaches the recruitment booth, answering any questions or concerns raised by the food bank member.  7. If food bank member displays interest, Researcher directs the member to the Research Coordinator to go through the Study Consent Form with the individual to further explain the study. If the Research Coordinator is reviewing consent with another member, the researcher can direct the member to another researcher that has been trained to go through the consent process. Proceed to protocols on Policy FB 020 to go through the entire consent process.    128 8. If the food bank member decides not to participate in the study or would like more time to decide: a. The researcher team member obtains a Physical Measurement Report and takes them through the different physical measurement stations should the food bank member desire to do so.  Proceed to Policy FB 040 for protocols on taking physical measurements. b. Research team member informs food bank member that they can approach the booth at another food bank visit anytime should they have more questions or if they decide to participate in the study.   9. If the food bank member decides to participate in the study, research team member directs the food bank member to the physical measures station and/or the interview station   10.  Prior to ending session with food bank member, research team member thanks food bank member for their time.   Handouts • Brochure • Letter of Initial Contact Documentation • Study Recruitment Form  Evaluation • Daily Research Progress Report • Review with GVFB        129 C.2 Policy 020: Study participant consent   Approved by: Principal Investigator  Effective Date: June 5, 2015 Revised: June 30, 2015  Policy Recruitment will be an open and safe process that is free of coercion. All members of the research team will be able to appropriately describe the research process and research goals to food bank members, and provide the information and time needed for the participant to provide consent.   Rationale To ensure all participants are able to provide free and informed consent.   Procedure  Obtaining Consent 1. Research team member to review and confirm eligibility with potential participant.   2. If the potential participant is eligible, research team member will give them a copy of the Informed Consent Form and provide them time to read through the form, or ask if they would like someone to review it with them.  3. Research team member to answer any questions, clarify areas of concern or misunderstanding, and review the Informed Consent Form with potential participants upon request.   4. If the individual decides immediately they would like to participate, research team member will: a. Request participant to indicate which data collection activities they will participate in b. Have participant sign the Informed Consent Form and provide them with a copy to take home.  c. Obtain contact information for participant d. Schedule participant to meet with an interviewer to complete the survey and/or focus group session.  5. If individual would like to have more time, or is unsure if they will participate, research member will: a. Provide a copy of the Informed Consent Form to take home b. Ask potential participant if one of the research team members could call them later to follow up. If potential participant says yes, obtain contact information. c. Let them know they may contact the Research Coordinator or come back to the research booth at the food bank at any time during the study should they choose to participate in the future.    130 6. If the individual decides that they would not like to participate, research team member will:  a. Thank them for their time  Once consent is obtained 7. Research team member to place participants name into the Master Participant List and assign them a unique code number to be used throughout the study.    8. Proceed to obtain and enter the member’s food bank membership number and contact number onto the Master Participant List.    9. Master Participant List will be encrypted as a password protected document that is kept with the Research Coordinator.  10.  The Research Coordinator proceeds to arrange an appointment with the participant for survey administration. The participant can choose the following options:  a. Date of survey administration:  this can be on the same day or another day of food bank visit b. Mode of survey administration: survey can be administered either in-person at the food bank site or on the phone.  11.  If the appointment for survey administration is scheduled for another day, the Research Coordinator ends the session by filling in the Appointment Cards with the date and mode of survey administration.  The appointment cards will then be handed to the participant.   Handouts • Informed Consent Form • Brochure • Appointment Cards Documentation • Informed Consent Form • Master Participant List Evaluation • Review with GVFB        131 C.3 Policy 030: Survey administration  Approved by: Principal Investigator  Effective Date: June 5, 2015 Revised: July 24, 2015  Policy Survey administration will take place via interviewer administered online surveys either on site at food bank locations, or by phone. All members of the research team will be familiar with the survey and how to engage in a survey interview using these survey administration guidelines.  Rationale To ensure all members of the research team understand the intent and protocol for survey administration to avoid interviewer bias.   Procedure 1. Prior to the appointment time, check to ensure the study participant has signed an Informed Consent form. If not, ensure you review consent form with the participant as per Policy FB 020 and obtain their consent prior to the survey.  2. Prior to the appointment time, take note of the code number that was assigned to participant during the consent process to be inputted into the survey.  3. Meet the study participant at the research booth at the scheduled appointment time. Introduce yourself to the study participant and vice versa to make the participant feel at ease.    4. Direct participant to the designated interview location for the particular food bank site, outside of earshot from other people in the area.   5. Briefly explain the purpose of the study, what information is being collected, and thank them for taking the time to complete the survey. It is important to point out that there are no wrong answers and that the interview is not a test. The study overview that is to be read to the participant is on the second page of the survey.   6. Key guiding points for making a good interview start:    a. You should be pleasant and assertive, and make the participant feel at ease.  b. You should know the survey tool inside and out and be prepared to answer any questions.  c. You should speak slowly and enunciate clearly to set the tone for the interview.  d. You should adapt your introduction to the participant, as different participants require different amounts of information. e. You should be motivated and interested in the interview.   7. Begin survey administration. Key guiding points for asking survey questions to ensure validity of data and avoid biased answers:   132 a. The conversation must follow the exact language set down in the survey. Read the questions as they are written in the text and do not change the wording.  b. Do not change the order of the questions.  c. Read the questions slowly and clearly. Italicized texts under questions are specific instructions pertaining to the question in how the interviewer should administer to the question. d. Read the questions in a pleasant voice that conveys interest and professionalism without added emotion or inflection. e. Maintain good eye contact and seated upright body posture f. Read entire question to the participant and make sure that s/he has heard it completely.  g. Do not skip questions even if the participant has given the answer earlier.  h. Verify information given by the participant earlier, acknowledging the information s/he has already provided. Do not make assumptions about the participant’s answers.  i. Administer survey questions by reading the module headings and its descriptions, followed by the questions in the modules.  j. Do not rush or pressure the participant for an answer. Give appropriate amount of time as needed for the participant to respond to the survey question.  k. Remain neutral to responses  8. Probe the participant only when necessary.  Begin probing by repeating the question and/or available answers, and giving the participant time to think. Ask an alternative, probing question if needed. Probing questions are provided under the bolded survey question.  Probing should occur when participant:  • Seems to understand the question but gives a response that is not appropriate • Does not seem to understand what is being asked.  • Misinterprets the question. • Cannot make up his/her mind.  • Digresses from the topic or gives irrelevant information.  • Needs to expand on what s/he has said or clarify his/ her response.  • Gives incomplete information or his/her answer is unclear. • Says that s/he doesn’t know the answer.  9. Once the survey is completed, thank the participant for their time according to the verbatim in the survey. Direct them to Research Coordinator who will provide them with the Thank You For Participating handout and their choice of bus tickets or $5 gift card for gas.   10. If not already completed, direct participant to proceed to the anthropometry station for obtaining blood pressure, waist & hip circumference, and handgrip strength measurements.   11.  All surveys must be interviewer administered, no participant may fill the survey out independently. Option available for research team member to call participant at home to complete survey via telephone if preferred by participant.   133 C.4 Policy 040: Physical safety for field research  Approved by: Principal Investigator  Effective Date: June 4, 2015 Revised: July 24, 2015  Policy All members of the research team will create an environment that promotes the safety of the research team, food bank members, and food bank volunteers. Any incident that threatens the physical safety or results in physical injury of any member of the research team, food bank members or volunteers will be documented and immediately reported to the principal investigator.  Rationale Safety needs to be monitored throughout the research process, and mitigated through planning and regular communication.   Guidelines:  1. Outline expectations for personal conduct for all research team members: a. Dress in a plain, non-provocative, and clean fashion (mindful of the dress of the population being interviewed) b. Limit jewelry and accessories  c. Display a relaxed, friendly, and pleasant demeanour d. Wear research badge prominently at all times e. Avoid using your cell phone while at the booth/on site f. Promote a friendly atmosphere at the booth  2. A minimum of 2 researchers must be present at each site for any research related activities.   3. One researcher must be present at the research booth at all times in order to: a. Be available to other researchers if needed b. Keep track of where other researchers and participant are on site c. Monitor equipment - If any of the equipment is not in use, it will be stored in a locked case.  4. Surveys and physical measurement collection are only permitted in pre-designated semi-private locations. These locations have been selected to maintain privacy for participants while ensuring that the researcher is not in an enclosed space where they can be barred from leaving.  Procedure:  1. Researcher to monitor for signs of behavioural escalation of participants, as outlined in conflict resolution training (i.e. - anxiety, defensiveness, challenging behaviour or   134 questioning, refusal to continue participating, emotional outbursts, displaying intoxicated behaviour that is affecting the research process etc.)   2. If researcher feels unsafe during a survey or physical measure collection due to disturbing participant behaviour or perceived threat to physical safety, the researcher is to terminate the survey or physical measurement collection immediately and remove themselves from the area.  3. Immediately inform other research team member about disturbing participant behaviour or physical safety risk.  4. Inform GVFB site coordinator about disturbing participant behaviour or physical safety risk.  5. If participant has been exhibiting disturbing or threatening behaviour, thank participant for their time and request the participant to leave the premises. If participant refuses to leave, or is making threats, call the police.   6. Notify the Principal Investigator.  7. Researchers hold a de-briefing session after each day of data collection, where any reactions or incidents related to physical risk are reviewed.  8. For any incident related to physical risks the researcher involved must document the incident using the Incident Form and provide this to the Research Coordinator to include in the Research Progress Report.   9.  Research Assistant or Principal Investigator will review the incident and outcome with the GFVB Intake and Evaluation Specialist that same day.  Documentation • Incident Form Evaluation • Research Progress Report • Assessment by Principal Investigator • Review with GVFB        135 C.5 Policy 050: Emotional and psychological distress  Approved by: Principal Investigator  Effective Date: June 4, 2015 Revised: July 24, 2015  Policy All members of the research team will monitor and ensure they are aware of cues or signals the participant may be exhibiting that are suggestive that the research process is too stressful, or causing emotional or psychological distress.   Rationale Participant wellbeing is of utmost importance, and their emotional safety needs to be monitored and mitigated throughout the research process through pre-planning and appropriate research team member response.   Procedure  1. Research team members to monitor for the following possible cues or signals of distress throughout the research activities: a. Participant expresses they are experiencing a high level of stress or emotional distress b. Participant tearing up or crying  c. Participant displaying incoherent speech, speaking quickly, shifting in their seat, using nervous gestures etc.  2. If any of these signs or other signs that the participant is uncomfortable are noted, researcher will pause the interview or physical measurement collection. Researcher to guide participant to private area if not already in one.   3. Researcher offers support by acknowledging emotional response. (i.e. – ‘I can see that you are upset’, ‘I can see that you are crying’.) Offer tissue, water or snack as appropriate.  4. Give the participant time to cry or express significant emotion as needed and allow the participant time to re-group.  5. Researcher will proceed to assess mental status by asking the following questions:  ‘Do you feel you are able to go on about your day?’ ‘Do you feel safe?’  a. If participants distress reflects an emotional response reflective of what would be expected in an interview about a sensitive topic, (i.e. – I am ok to go on/I feel safe, that question made me feel sad for a moment but I am ok now, I don’t normally like to think about that topic) offer support and allow the participant the choice of either:  i. Terminating the interview    136 ii. Continuing the interview  b. If the participant’s distress reflects acute emotional distress or a safety concern beyond what would be expected in an interview (I don’t feel safe, I am not ok to continue about my day) but not imminent danger: iii. Stop the interview iv. Provide the participant with contact information for crisis support (available on the back of the Thank You handout) v. Encourage participant to use these resources if he/she experiences increased distress vi. Indicate that, with the participant’s permission, a team member will contact him/her the next day to see if he/she is ok  c. If the participant’s distress reflects imminent danger, and you fear for their or your safety: vii. Notify your on-site research team members immediately viii. Contact local law authorities and arrange for the participant to be transported to the emergency room ix. Indicate that, with the participant’s permission, a team member will contact him/her the next day to see if he/she is ok x. Notify the Principal Investigator immediately  6. For any incident related to emotional or psychological distress, the researcher involved will document the incident using the Incident Form immediately following the incident, and provide to the Research Coordinator to include in the Research Progress Report.  7. Researchers hold a de-briefing session after each day of data collection where any reactions or incidents related to psychological or emotional distress will be reviewed.  8. Research Assistant or Principal Investigator will follow up with the researcher involved and review the incident and outcome with the GFVB Intake and Evaluation Specialist that same day.  9. If participant agreed to allow research member to contact them the following day, Research Coordinator or Principal Investigator to call to review incident with participant, check in on their welfare, and provide information/ encourage participant to use crisis resources as appropriate.  Documentation • Incident Form Evaluation • Research Progress Report • Assessment by Principal Investigator • Review with GVFB  • Review with Participant via telephone (with their consent)    137 Appendix D  Survey results Module 1: Transportation    Sample characteristics   n % Site location used at time of survey (n=77) A 12 16  B 25 32  C 40 52 Transportation method used to get to the FB (n=77) Walk 48 62  Public transit 19 25  Bicycle 5 6  Car 4 5   Scooter 1 1 Note: Total n=77. Sample size differed between variables due to missing values. Some totals not equal to 100% due to rounding. FB = food bank      Module 2: Experience using food banks     Sample characteristics   n % Positive experience at the FB (n=77) Agree/strongly agree 62 81  Neutral 10 13  Disagree/strongly disagree 5 6 Feel safe at the FB (n=77) Agree/strongly agree 66 86  Neutral 4 5   Disagree/strongly disagree 7 9 Feel respected by volunteers (n=77) Agree/strongly agree 66 86  Neutral 9 12  Disagree/strongly disagree 2 3 Feel respected by members (n=77) Agree/strongly agree 62 81  Neutral 5 6   Disagree/strongly disagree 10 13 Knowledge on how to access community resources (n=76) Agree/strongly agree 61 80  Neutral 7 9  Disagree/strongly disagree 8 11 Found out about other resources at the FB (n=77) Agree/strongly agree 41 53  Neutral 10 13   Disagree/strongly disagree 26 34 Interest in community services at the FB (n=77) Agree/strongly agree 59 77  Neutral 5 6  Disagree/strongly disagree 13 17 Interest in members assisting with sign-up (n=77) Agree/strongly agree 46 60  Neutral 17 22   Disagree/strongly disagree 14 18   138     Sample characteristics   n % Knowledge to share with other FB members (n=77) Agree/strongly agree 42 55  Neutral 16 21  Disagree/strongly disagree 19 25 FB information access points (n=77) Friends 30 39  Food bank volunteers 18 23  Food bank members 9 12  Food bank website 9 12  Head office - phone 5 6  Head office - in person 2 3  Posters 2 3   Other 20 26 Change in hunger (n=77) Decreased 28 36  Stayed about the same 42 55  Increased 7 9 Number of days food provisions last (n=76) ≤ 1 day 3 4  2 - 3 days 38 50  4 - 5 days 16 21  6 - 7 days 15 20   > 7 days 4 5 Unmet need (n=77) Yes – FB provides enough 23 30  No – FB doesn’t provide enough 48 62  Sometimes – FB provides enough 6 8 Food preferences  Meats and alternatives 56 73  Fruits and vegetables 50 65  Milk and alternatives 33 43  Grain products 23 30  Other food items 29 38   Other non-food items 15 19 Self-reported length of use (n=76) < 1 year 12 16  1 - 5 years 39 51  > 5 years 25 33 Self-reported frequency of use - past 3 months (n=77) Low (< 3 visits) 9 12  Medium (3 - 6 visits) 12 16   High (> 6 visits) 56 73 Projected FB use in 3 months (n=77) Yes 69 90  Don’t know/other 8 10   No 0 0 Note: Total n= 77. Sample size differed between variables due to missing values. Some totals not equal to 100% due to rounding. FB = food bank       139 Module 3: Food preparation and access    Sample characteristics   n % Reported access to the following (n=77): A working stove or hotplate 75 97  A microwave 65 84  A working refrigerator 76 99  A working freezer 61 79  An area to store food 75 97 Self-reported cooking skill (n=77) Excellent/good 58 75  Average 13 17   Fair/poor 6 8 Dietary restrictions (n=77) No 40 52  Yes 37 48 Dietary restriction types (n=77) Dental  11 14  Allergy 9 12  Health/therapeutic diet 7 9  Food intolerance (lactose, sensitivity) 5 6  Cultural 3 4   Vegetarian 1 1 Food access points  Grocery store 75 97  Friends/family 38 49  Free meal program 38 49  Fast food 34 44  Not for profit grocery store 24 31  Restaurant 21 27  Garden 20 26  Low cost meal program 17 22   Community kitchens 11 14 Note: Total n= 77. Sample size differed between variables due to missing values. Some totals not equal to 100% due to rounding         140 Module 4: Household size and structure    Sample characteristics   n % Housing type (n=77) Apartment 56 73  Rooming house 8 10  Basement suite 6 8  Partially detached home 3 4  Detached home 2 3  No fixed address 2 3 Home ownership (n=77)  Renter 74 96   Homeowner 3 4 Monthly housing/mortgage costs (n=76) $0 - 500 42 55  $501 - 1000 31 41  > $1000 3 4 Household size (n=77) 1 45 58  2 15 19  3 11 14   ≥ 4 6 8 Children (<18 years old) in household (n=77) No 69 90  Yes 8 10 Household structure (n=77) Single individual household 45 58  Adult only - related family members 13 17  Adult only - room-mates/friends 11 14  Two or more adults with children < 18 6 8   Single parent with children < 18 2 3 Note: Total n= 77. Sample size differed between variables due to missing values. Some totals not equal to 100% due to rounding         141 Module 5: Employment and income    Sample characteristics   n % Employment at time of survey (n=77) No 62 81   Yes 15 19 Number of jobs currently employed (n=15) 1 13 87   > 1 2 13 Employment part-time or full-time (n=15) Part-time (< 40 hours per week) 11 73   Full-time (≥ 40 hours per week) 4 27 Hourly wage of employment (n=15) < $10.25 3 20  $10.25 - 14.99 8 53  ≥ $15.00 4 27 Household income source (all sources) Income support - all types but pensions 65 84  Disability assistance 47 61  Wages 22 29  Government pension (CPP, OAS, GIS) 19 25   Other  12 16 Other sources of household income  Occasional work 5 6  Honorarium 2 3  Family members 1 1  Widows pension 1 1  Government transfer for foster children  1 1  Annuities from residential school 1 1  Student loan 1 1 Household income (n=77) $0 – 599 9 12  $600 - 1199 43 56  $1200 - 1799 17 22   ≥ $1800 7 9 Work in position where not paid for their time (n=77) No 35 45  Yes - volunteering 32 42  Yes - caregiving for child  6 8   Yes - caregiving for adult 4 5 Note: Total n= 77. Sample size differed between variables due to missing values. Some totals not equal to 100% due to rounding         142 Module 6&7: Household food insecurity     Sample characteristics   n % Household food insecurity1 (n=74) Food secure 2 3  Marginal food insecurity 1 1  Moderate food insecurity 22 30   Severe food insecurity 49 66 Reducing food intake for non-financial reasons (n=76) No 52 68   Yes  24 32 Note: Total n= 77. Sample size differed between variables due to missing values.      Module 8: Demographic data    Sample characteristics   n % Gender (n=76) Male 45 59   Female 31 41 Age (n=76) 18 – 39 13 17  40 – 64 51 67  ≥ 65 12 16 Ethnic/cultural background (n=75) White/Caucasian 35 47  First Nations/Metis/Inuk 18 24  Chinese 3 4  Iranian 3 4  Southeast Asian 3 4  Black - Caribbean 2 3   Other - unspecified 11 15 First generation immigrant to Canada (n=76) Yes 18 24  No 58 76 Time living in Canada (n=18) < 1 year 1 6  1 - 5 year 1 6   > 5 years 16 89 Education level (n=76) Less than secondary school 31 41  Secondary school diploma 13 17  Some college 19 25  College diploma 2 3  Trade certificate/diploma 4 5  University degree below bachelor 4 5   Bachelor degree or higher 3 4 Education completed in Canada (n=76) Yes 60 79  No 16 21 English reading skill (n=76) Excellent or good 52 68  Average 14 18   Fair or poor 10 13 Note: Total n= 77. Sample size differed between variables due to missing values.    143 Module 9: Health indicators    Sample characteristics   n % Visited doctor in the year prior to the survey (n=76) Yes 70 92  No 6 8 Visited dentist in the year prior to the survey (n=76) Yes 40 53   No 36 47 Did not visit dentist because: (all that apply) (n=36) Busy 2 6  Participant believed unnecessary 9 25  Cost 16 44  No dental coverage 5 14  Fear 3 8  No teeth 6 17  Dislikes the dentist 2 6  Difficulty sitting in dental chair 1 3  Sees hygienist 1 3 Perceived physical health (n=76) Excellent 2 3  Very good 12 16  Good 33 43  Fair 20 26   Poor 9 12 Perceived mental health (n=75) Excellent 13 17  Very Good 14 19  Good 22 29  Fair 20 27   Poor 6 8 Health issue (n=77) Any reported health issue(s) 59 78  Hypertension 22 29  Chronic pain 14 18  Mental health concern 12 16  Diabetes 10 13  Cancer 5 7  Liver disease 5 7   Lung disease 4 5 Heart attack - biological parent (n=76) Yes 38 50  No 29 38   Don't know 9 12 Smoking status (n=76) Never smoked 15 20  Former smoker 11 14   Current smoker 50 66 Current smokers - number of daily cigarettes  (n=50) < 10 cigarettes 22 44  10 - 19 cigarettes 13 26   ≥ 20 cigarettes 15 30   144 Sample characteristics   n % Exposure to second hand smoke (n=75) < 1 hour or no exposure per week 29 39   ≥ 1 hour per week 46 61 Stress exposure in the past year (n=76) Never 11 14  Some periods of stress 24 32  Several periods of stress 30 39   Permanent or chronic stress 11 14 Felt sad, blue, or depressed in the past year (n=75) No 38 51   Yes 37 49 Activity level (n=76) Mainly sedentary 9 12  Mild exercise 33 43  Moderate exercise 26 34   Strenuous exercise 8 11 Salty food intake, per day (n=76) < 1 time per day 54 71  1 - 2 times 18 24   > 2 times 4 5 Deep fried and fast food, per week (n=76) < 1 time per week 57 75  1 - 2 times per week 14 18   > 2 times per week 5 7 Meat and poultry, per day (n=76) < 1 time per day 69 91  1 - 2 times per day 7 9   > 2 times per day 0 0 Fish and seafood, per day (n=75) < 1 time per day 72 96  1 - 2 times per day 3 4   > 2 times per day 0 0 Total meat, poultry, fish, and seafood, per day (n=76) < 1 time per day 62 82  1 - 2 times per day 11 14   > 2 times per day 3 4 Fruit, vegetable, and juice, times per day (n=76) < 1 time per day 23 30  1 - 1.9 times per day 22 29  2 - 2.9 times per day 11 14  3 - 3.9 times per day 9 12  4 - 4.9 times per day 7 9  ≥ 5 times per day 4 5 Fruit, vegetable, and juice, servings per day (n=76) < 1 serving per day 19 25  1 - 1.9 servings per day 16 21  2 - 2.9 servings per day 15 20  3 - 3.9 servings per day 7 9  4 - 4.9 servings per day 4 5   ≥ 5 servings per day 15 20 Note: Total n= 77. Sample size differed between variables due to missing values. Some totals not equal to 100% due to rounding    145 Appendix E  Sensitivity analysis with imputations for missing MMS use data  E.1 Length and frequency of food bank use  Sample characteristics   n % Length of use1 (n=77) < 1 Year 6 8  1 - 5 years 31 40   > 5 years 40 52 Frequency of use2 (n=77) Low (< 1/month) 8 10  Medium (1 - 2/month) 22 29   High (> 2/month) 47 61 Note: Total n= 77.     1. Calculated from participants' first recorded visit in the GVFB MMS database or if MMS data not available, imputed from self-reported length of use  2. Calculated from participants' number of visits over the past quarter in the MMS database or if MMS data not available, imputed from self-reported frequency of use over the past quarter  E.2 Associations between length and frequency of use and severe HFI 	  Sample characteristics Severe HFI   Fisher's     No Yes Total exact Length of use1        < 1 Year 1 (17%) 5 (83%) 6 (8%)    1 - 5 years 12 (40%) 18 (60%) 30 (41%)   > 5 years 12 (32%) 26 (68%) 38 (51%)    TOTAL 25 49 74 p = 0.57 Frequency of use2      Low (< 1/month) 2 (29%) 5 (71%) 7 (9%)   Medium (1 - 2/month) 7 (32%) 15 (68%) 22 (30%)   High (> 2/month) 16 (36%) 29 (64%) 45 (61%)    TOTAL 25 49 74 p = 1.00 Note: Total n= 77. Sample size differed between variables due to missing values. * p = <0.05 1. Calculated from participants' first recorded visit in the GVFB MMS database or if MMS data not available, imputed from self-reported length of use  2. Calculated from participants' number of visits over the past quarter in the MMS database or if MMS data not available, imputed from self-reported frequency of use over the past quarter     146 Appendix F  Supplementary tables F.1 Associations between alternative categorization of income and housing costs and severe HFI  Sample characteristics   Severe HFI   Fisher's     No Yes Total exact Monthly household income      $0 - 599  3 (33%) 6 (67%) 9 (12%)   $600 - 1199 12 (29%) 29 (71%) 41 (55%)   $1200 - 1799 5 (31%) 11 (69%) 16 (22%)   $1800 - 2399 1 (50%) 1 (50%) 2 (3%)   ≥ $2400 4 (80%) 1 (20%) 5 (7%)   Total 25 48 73 p = 0.28 Monthly household income      $0 - 1199 15 (30%) 35 (70%) 50 (68%)   ≥ $1200 10 (43%) 13 (56%) 23 (32%)    TOTAL 25 48 73 p = 0.30 Monthly housing costs       $0 - 1000 25 (36%) 45 (64%) 70 (96%)   > $1000 0 (0%) 3 (100%) 3 (4%)    TOTAL 25 49 74 p = 0.55 Note: Total n= 77. Sample size differed between variables due to missing values. * p = <0.05        F.2 Association between income and severe HFI, controlled by housing costs  Sample characteristics   Severe HFI    Fisher's     No Yes Total exact Monthly income and housing costs      ≥ $1800 / ≤ $500 3 (100%) 0 (0%) 3 (4%)   ≥ $1800 / > $500 2 (50%) 2 (50%) 4 (54%)   < $1800 / ≤ $500 16 (44%) 20 (56%) 36 (49%)   < $1800 / > $500 4 (13%) 26 (87%) 30 (41%)   TOTAL 25 48 73 p = 0.001** Note: Total n= 77. Sample size differed between variables due to missing values. *p = <0.05  **p = <0.01         147 F.3 Associations between hunger decrease and adequacy of food bank provisions and severe HFI Sample characteristics   Severe HFI    Fisher's     No Yes Total Exact Hunger decrease since initial food bank use    Yes 8 (29%) 20 (71%) 28 (38%)   No1 17 (37%) 29 (63%) 46 (62%)    TOTAL 25 49 74 p = 0.61 Adequacy of food bank provisions      Yes2 13 (46%) 15 (54%) 28 (38%)   No 12 (26%) 34 (74%) 46 (62%)    TOTAL 25 49 74 p = 0.08 Note: Total n= 77. Sample size differed between variables due to missing values. * p = <0.05 1. Includes both ‘no change’ and ‘increased’ responses 2. Includes both ‘yes’ and ‘sometimes’ response  F.4  Associations between length and frequency of food bank use and hunger decrease Sample characteristics   Hunger decrease    Fisher's     No1 Yes Total exact Length of use       < 1 Year 4 (100%) 0 (0%) 4 (5%)    1 - 5 years 17 (57%) 13 (43%) 30 (41%)   > 5 years 26 (65%) 14 (35%) 40 (54%)    TOTAL 46 28 74 p = 0.30 Frequency of use, monthly visits      Low (< 1) 8 (73%) 3 (27%) 11 (16%)   Medium (1 - 2) 11 (58%) 8 (42%) 19 (28%)   High (> 2) 23 (62%) 14 (38%) 37 (55%)    TOTAL 42 25 67 p = 0.69 Note: Total n= 77. Sample size differed between variables due to missing values. * p = <0.05 1. Includes both ‘no change’ and ‘increased’ responses         148 F.5 Associations between length and frequency of use and adequacy of food bank provisions Sample characteristic   Adequacy of food provisions  Fisher's     No Yes1 Total exact Length of use       < 1 Year 3 (75%) 1 (25%) 4 (5%)    1 - 5 years 17 (57%) 13 (43%) 30 (41%)   > 5 years 26 (65%) 14 (35%) 40 (54%)    TOTAL 46 28 74 p = 0.67 Frequency of use, monthly visits      Low (< 1) 6 (55%) 5 (45%) 11 (16%)   Medium (1 - 2) 13 (68%) 6 (32%) 19 (28%)   High (> 2) 23 (62%) 14 (38%) 37 (55%)    TOTAL 42 25 67 p = 0.74 Note: Total n= 77. Sample size differed between variables due to missing values. * p = <0.05 1. Includes both ‘yes’ and ‘sometimes’ response                            149 Appendix G  Comparison of food bank member sample and population characteristics Characteristics   Sample Population1     n  (%) N (%) Gender  Male 45 (59) 599 (55)   Female 31 (41) 469 (43) Household size  1 45 (58) 670 (62)  2 15 (20) 202 (19)  3 11 (14) 83 (8)   ≥ 4 6 (8) 130 (12) Length of use < 1 Year 4 (5) 274 (27)  1 - 5 Years 30 (41) 365 (36)   > 5 Years 40 (54) 375 (37) Frequency of use, monthly visits Low (< 1) 11 (16) 241 (27)  Medium (1 - 2) 19 (28) 252 (29)   High (> 2) 37 (55) 387 (43) Note: Total sample n= 77. Total population available in sampling frame N = 1085. Sample size differed between variables due to missing values 1. Calculated from the total number of unique food bank members attending the 3 food bank survey sites over the recruitment period  

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