Food pantries as partners in population health: Assessing organizational and personnel readiness for delivering nutrition-focused charitable food assistance

ABSTRACT

Food pantries serve populations with high rates of chronic disease and thus may be ideal settings for community-based health promotion programs. This study aimed to describe the readiness of food pantry organizations (n = 69) and their personnel (n = 129) to engage in nutrition-focused food pantry services, including nutrition education and the application of dietary guidelines for disease prevention and management as components of existing food assistance programs. Among survey respondents, few personnel reported asking clients about chronic disease diagnoses or providing clients with nutrition education, and over half reported lower confidence in performing these activities. Yet, the majority were interested in training to address client health needs. However, organizational capacity is currently restricted by lack of nutrition policies and limited healthy food inventory, including fruits and vegetables. To address the nutritional needs of clients, food pantries may benefit from in-person training and additional resources to obtain and distribute healthier foods.

KEYWORDS:

• Food pantry
• food shelf
• food insecurity
• food access
• nutrition
• fruits
• vegetables
• health disparities

Introduction

The charitable food system, comprised a diverse network of over 58,000 grocery programs, kitchens, and shelters, serves approximately 46.5 million Americans, or 15.5 million households, each year.¹ The vast majority of these clients—nearly 44 million—are served through grocery programs that most commonly operate as food pantries.¹ While initially developed for emergency food aid, food pantries now primarily serve clients on a routine basis, most of whom are food insecure,¹ a household condition of limited or uncertain access to adequate food.² The association of food insecurity with nutrition-related chronic conditions, including diabetes,^3,4 hypertension,³ and obesity among women,^4,5 has led to the proposal of food pantries as community-based intervention sites for the delivery of additional health-related programs and other nutrition-focused services.⁶ Successful implementation of new health promotion initiatives into existing food assistance services assumes a certain commitment to these health promotion activities by food pantry providers, as reflected by organizational culture and routine practices of personnel.⁷ Yet, little is known about the organizational readiness of food pantries to engage in health promotion initiatives, including organizational capacity to deliver healthy foods and nutrition education, or personnel ability and interest to provide these services.

Food pantry programs are operated by a collection of nearly 32,000 nonprofit organizations that are structurally, culturally, and religiously diverse, yet few are operated by organizations in the medical or public health sectors.¹ Although there are some notable exceptions, most food pantry programs have historically prioritized food quantity (i.e., pounds or bags of food) over nutritional quality with a primary aim to provide foods as a means for ministry or hunger relief, or as a component of other social service programs.⁸ Foods are generally distributed through one of three types of food pantry models: traditional, semi-choice, and choice. The majority of studies on the nutritional quality of charitable foods have not explored differences in these models,^9–11 but these studies generally indicate misalignment of food pantry inventory with dietary guidelines, primarily due to food inventories that lack fresh foods and that heavily rely on shelf-stable, processed foods.^10–12 Choice models have been shown to be highly preferred by clients,¹³ with one longitudinal, randomized control intervention suggesting that this model can improve client fruit and vegetable intake when compared to traditional models.¹⁴ However, little to no research has investigated whether choice models are associated with organizational capacity for delivering healthy foods and nutrition education compared to traditional or semi-choice models.

Even less is known about the workforce who staffs food pantry programs as it relates to the delivery of nutrition-focused pantry services. These food pantry personnel include paid employees and volunteers from diverse backgrounds, and personal characteristics may relate to individual inclination toward providing nutrition education. Studies exploring motivations for food pantry work have suggested religiosity, social connections, or personal connectedness to a cause as key factors.^15,16 One study concluded that food pantry volunteers may often be current or past food pantry users who have personally experienced food insecurity.¹⁷ More information is needed on the proportion of food pantry personnel that routinely engage in nutrition-related practices, and which characteristics are associated with an interest in nutrition-related training opportunities.

Identifying organizational factors associated with the uptake of nutrition initiatives has important implications for food banks, whose leaders are increasingly recognizing the need to consider hunger and health as interrelated issues.^18,19 Food banks have increased fresh fruit, vegetable, and other healthy food sourcing efforts, which may not be utilized equally by partner agency members, resulting in inequitable food access for clients. Likewise, a variety of nutrition-focused interventions at the food pantry level have been proposed or piloted, ranging from behavioral nudges²⁰ and healthy food labeling²¹ to medically tailored food assistance for people with diabetes⁶ or people with HIV/AIDS²²; yet, the personnel and organizational characteristics associated with the uptake of nutrition-focused services are not consistently considered in the literature. To successfully scale nutrition initiatives in these community settings, food banks need more information on the factors that influence partner program readiness to implement these initiatives.

The Food Independence, Security, and Health (FISH) Project was developed through a university-food bank research partnership with Oklahoma’s two food banks that collectively provide food assistance to one out of six people in the state.²³ The long-term goals of this conceptual project are to reduce health disparities among persons accessing Oklahoma food pantries and to identify sustainable solutions for improving food security among client households seeking food aid. Collaborating food banks include the Community Food Bank of Eastern Oklahoma (CFBEO), which partners with over 200 food pantries that serve clients residing in the 24 counties of eastern Oklahoma, and the Regional Food Bank of Oklahoma (RFBO), which partners with over 350 food pantries that serve clients residing in the 53 counties of central and western Oklahoma.

The FISH survey consisted of a statewide assessment of food pantries to identify and prioritize opportunities for pantry-based health interventions, which included client-, personnel- and organizational-level surveys. This study presents descriptive findings from the personnel- and organizational surveys to address multiple knowledge gaps regarding personnel and organizational-level readiness to provide nutrition-focused client services, defined as nutrition education and the application of dietary guidelines for disease prevention and management, within food pantry settings. Specifically, among food pantry personnel, (1) what nutrition-related practices do personnel currently provide when delivering food pantry services? (2) Do personnel have the knowledge, confidence, and interest to address nutritional needs of clients, and what characteristics are associated with pantry personnel who currently deliver and who are interested in training for nutrition-focused services to clients? Among food pantry organizations, (3) what is the current capacity to address clients’ nutritional needs? (4) Are client choice food pantry models associated with nutrition-focused food pantry practices?

Methods

Personnel and organizational sampling strategy

This study sampled from active pantry organizations affiliated with one of the two food banks in Oklahoma who reported distributing more than 1000 pounds of food per year, but sampling differed by food bank region. In eastern Oklahoma, pantries were stratified according to their geographic designation: metropolitan, micropolitan, and small town/rural, then proportionate probability sampling (PPS) was used within each strata to obtain a representative sample of pantries in that stratum. Next, up to 5 personnel were randomly sampled from the 25 pantries selected using the PPS method. These 25 pantries were also invited to complete an organizational survey, and an additional 75 pantries were selected with PPS to reach our organizational survey sampling goal of 100 CFBEO pantries. In central/western Oklahoma, at the request of the RFBO, all active food resource centers (FRCs) (n = 9) were purposively sampled for organizational surveys and up to 10 personnel were randomly sampled from each FRC. These FRCs are larger choice pantries that offer additional social services, such as case management.

Recruitment

The designated contact for each pantry agency selected to complete the organizational survey was emailed an invitation to submit an organizational survey on behalf of their organization. Food bank leadership also sent separate emails to agency contacts announcing the survey opportunity. Food pantries received a $50 food bank credit and FRCs received a $100 food bank credit for completion of an organizational survey. The researchers coordinated with the contacts of selected agencies to schedule recruitment times and dates for completion of personnel surveys. Personnel unable to complete the survey in person were given the option to complete the survey by email. Personnel received a $10 gift card for completion of the personnel survey. The FISH survey was approved by the University of Oklahoma Health Sciences Center IRB.

Survey design and administration

University researchers developed surveys in consultation with representatives from the CFBEO, the RFBO, and Feeding America to collect personnel and organizational information from pantries described in the sampling. Most items included on these surveys were questions from previous standardized surveys, including the US Household Food Security Survey Module, the Hunger in America 2014 Survey, Behavioral Risk Factor Surveillance Survey (BRFSS), and the Adult Tobacco Survey (ATS). Items from the BRFSS and ATS were adapted for self-administration. Various unpublished food pantry capacity assessment tools were consulted and used to develop new questions when standardized questions were unavailable. Surveys were administered via REDCap²⁴ primarily on tablets or laptops with some paper survey administration when electronic collection was not feasible or upon participant request. Data were collected between April and October 2016.

Personnel survey items used for the analyses

Demographic questions included self-reported age, sex, race/ethnicity, education, income, and marital/partner status. Total household income reported in $5000 increments from 0 to above $50,000 was recategorized as ≤$20,000, $20,001–$50,000, and >$50,000. Education was reported in seven levels but recategorized into four groups for analysis: less than high school, high school diploma or GED, some college or technical school, college degree or more. Food security-related questions included the 10-item adult household food security module,²⁵ and self-reported food-assistance program use (current, past, or never) for three separate programs: food pantries, the United States Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP), and the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Health-related personnel questions included self-reported diagnosis of diabetes and/or hypertension, a method found to be valid in past studies comparing self-reported diagnosis with patient medical records,²⁶ and self-reported height and weight for the classification of participant body weight based on BMI, including underweight, normal weight, overweight, and obese. A single-item measurement of health literacy asked “How confident are you filling out forms by yourself?” Participants responding either “extremely” or “quite a bit” were categorized as having adequate health literacy while responses of “somewhat,” “a little bit,” and “not at all” were categorized as marginal/inadequate health literacy.²⁷ Personnel were also asked about their food pantry work, including their length of service and work responsibilities at the food pantry, such as food ordering, food stocking, and assisting clients with food or referrals.

Current personnel practices and perceptions regarding nutrition-focused pantry services

Frequency of current nutrition-related practices of personnel was assessed with six questions, including: talking to clients about how to follow a healthy diet, discussing basic diet guidelines for client chronic health conditions, asking clients if they have been diagnosed with a chronic health condition, such as diabetes or heart disease, making SNAP and WIC referrals, and collection of body weight using a 5-point Likert scale, ranging from never to always.

Personnel perceptions of whether nutrition should be integrated into pantry services were assessed with three questions, including whether it is acceptable to ignore the nutrition needs of clients, whether providing diabetic-friendly foods to help clients with diabetes should be part of their job, and whether they think clients who come to the pantry for food would listen to their advice on healthy eating.

Personnel perceptions about whether clients would be receptive toward nutrition-focused pantry services were assessed using a 4-point Likert scale ranging from strongly agree to strongly disagree for the following statements: most food pantry clients will select fruits and vegetables if given the choice, most food pantry clients are not interested in changing their eating behaviors, and most food pantry clients do not know the health risks of poor nutrition.

Knowledge, confidence, and interest in training

Personnel were asked whether they felt they had sufficient knowledge to talk with food pantry clients about eating behaviors, such as following a healthy diet. Personnel were also asked whether not having proper nutrition increases a person’s risk for diabetes, heart disease and high blood pressure, or obesity including the 4-point Likert scale response options ranging from strongly agree to strongly disagree. Personnel were asked to rate their confidence in assisting clients with five nutrition-related services on a 4-point Likert scale, ranging from very confident to not at all confident.

Personnel interest in nutrition-related training was assessed with three questions, including whether they would be interested in training on addressing client health needs and if they would like to help food pantry clients find ways to improve their diet and prepare food pantry groceries, with response options of yes or no. Preferred delivery methods of training were also collected.

Organizational survey items used for the analyses

Questions used to characterize organizations included religious affiliation; the number of years in operation; the number of households and unduplicated clients served monthly; the number of full-time staff, part-time staff, and weekly volunteers; and whether the pantry was open at least once a week. Organizational capacity to store perishable foods was assessed by asking whether refrigerated and freezer storage were available.

Pantry agencies were classified into one of three models based on the following descriptions: clients receive a predetermined selection of groceries (traditional), clients receive a selection of groceries based on reported preferences (semi-choice), or clients are allowed to make their own grocery selections (full choice). For those indicating use of a choice or semi-choice model, length of time was reported in five categories (less than 1 year, 1–3, 4–5, 6–10, 10+ years), which were recategorized in the analyses as less than 1 year, 1–3 years, and 4 or more years.

To measure organizational appraisal of whether clients would be receptive toward nutrition-focused pantry services, respondents were asked how their organization would describe client interest in receiving advice on healthy eating and in receiving more healthy food options with the response options for these two questions of very interested, indifferent, and not interested.

Nutrition-related practices of food pantry organizations

Current organizational policies and services of pantry agencies were assessed, including questions about whether the organization had a written nutrition policy regarding food procurement and whether nutrition guidelines were used, specifically MyPlate²⁸ (meal planning guidelines developed by the USDA Food and Nutrition Service), Foods to Encourage (healthy food inventory goals for food banks and food pantries developed by Feeding America that are based on MyPlate and the USDA Dietary Guidelines for Americans),²⁹ and food safety guidelines. Organizations were also asked to report how often they accessed the Healthy Food Bank Hub (currently Hunger and Health) website, which is sponsored by Feeding America and provides a compilation of health-related educational materials, recipes, publications, and program development resources for food pantries and food banks.³⁰ To assess direct efforts to engage clients, organizations were asked to indicate whether they did any of the following: distributed nutrition education materials, offered interactive nutrition workshops such as cooking or food budgeting classes, or employed or collaborated with registered dietitians or dietetic student interns. They were also asked whether their organization collects health-related client data, such as self-reported diabetes, hypertension, or kidney disease; food allergies or intolerances; and client weight. Additionally, other current services and referrals by pantry organizations were assessed by asking what other types of assistance besides food are provided, including SNAP/Food stamp application assistance and medical clinics, with responses of primarily providing assistance onsite, referring clients to another provider, or not routinely providing or referring for this type of assistance.

Healthy food inventory and distribution

Finally, organizations were asked to describe the availability and adequacy of healthier foods. Organizations rated availability using a 5-point Likert scale ranging from never/almost never (0–10%) to always/almost always (90–100%) to describe how often each food is available to clients for the following food items: fresh and frozen fruits, fresh and frozen vegetables, low sodium canned vegetables, lower sugar canned fruit, eggs, nuts/seeds, beans, and milk alternatives. Respondents were also asked whether their organization would prefer to receive more, about the same, or less of these foods. Duration of fresh fruit and vegetable distribution was also assessed.

Data analysis

Perceptions, knowledge, and confidence of pantry personnel and current practices of organizations related to nutrition-focused pantry services were estimated from questions on their respective surveys. Responses of “strongly agree” and “agree” were categorized as “agree,” responses of “very confident” and “confident” were categorized as “confident,” responses of “always” and “almost always” were categorized as “regularly” for all analyses using Likert-scale questions. Chi-squared tests were used to assess relationships between categorical variables, such as, whether personnel characteristics were associated with a desire to engage in nutrition-related client activities. Fisher’s exact tests were used when categorical variables did not meet the assumptions for the chi-squared test. Organizational survey analyses were stratified by food pantry type (traditional, semi-choice, and choice) to assess differences in organizational practices or other characteristics that may relate to readiness for nutrition-focused service delivery. SAS 9.4 was used for all statistical analyses.

Results

Food pantry personnel

Among the 129 participating personnel, the majority of personnel were middle-aged (median age: 61 years; range 19–88), female (74.4%), white (82.4%), earned over $20,000 per year (75%), had some college education (70.2%), and were health literate (84.9%). Furthermore, the majority were overweight or obese (72.9%), over one-third reported a diagnosis of hypertension (36%) and 8.5% reported a diabetes diagnosis. While most personnel reported high food security (71.3%), one in six (17.2%) met the designation criteria for food insecurity, over one-third (35.5%) reported past or current use of food pantries, and one-quarter reported current or past use of SNAP (25.6%) (Table 1).

Table 1. Personal characteristics of food pantry personnel in Oklahoma, n = 129.

Characteristic	n (%)
Age, median (range)	61 years (19–88 years)
Sex
Female	93 (74.4)
Male	32 (25.6)
Race/Ethnicity
White	103 (82.4)
Black	7 (5.6)
American Indian	10 (8.0)
Hispanic	7 (5.7)
Don’t know/Prefer not to say	5 (4.0)
Household income
≤$20,000	29 (25.0)
$20,001–50,000	45 (38.8)
>$50,000	42 (36.2)
Education
Less than high school	7 (5.6)
High school diploma/GED	30 (24.2)
Some college/Technical school	41 (33.1)
College degree or more	46 (37.1)
Health literacy
Adequate	101 (84.9)
Marginal/Inadequate	18 (15.1)
Food security status
Very low food security	8 (6.6)
Low food security	13 (10.7)
Marginal food security	14 (11.5)
High food security	87 (71.3)
Use of food pantries
Past or current use	44 (35.5)
Never used the program	80 (64.5)
Use of SNAP
Past or current use	31 (25.6)
Never used the program	90 (74.4)
Use of WIC
Past or current use	22 (18.3)
Never used the program	98 (81.7)
Weight
Underweight	1 (0.9)
Normal weight	29 (26.1)
Overweight	38 (34.2)
Obese	43 (38.7)
Diagnosed with hypertension
Yes	47 (36.4)
Diagnosed with diabetes
Yes	11 (8.5)

Current nutrition-related practices

The median time of pantry service was nearly 3 years. Nearly one-third of pantry personnel reported they were currently assisting clients with pantry shopping (32.6%), over half prepared food bags (54.3%), and almost one-third (32.6%) reported providing referrals or information to clients as part of their job (Table 2). However, few pantry personnel (13.9%) reported asking clients about chronic health conditions and less than 10% reported regularly providing general healthy diet education (9.0%) or disease-specific diet education (9.8%) to clients. Yet, the majority (87.2%) of personnel agreed that ignoring the nutritional needs of pantry clients was unacceptable, 81.1% said that providing diabetic-friendly foods should be part of their job, and 68.0% indicated a desire to help clients find ways to improve their diet. This desire was unrelated to personnel hypertension or diabetes diagnosis, health literacy, food pantry or SNAP use, gender, race/ethnicity, education, or income. Most pantry personnel (63.3%) also indicated a desire to help clients prepare pantry groceries. A greater proportion of women reported this desire to help clients prepare groceries than men (69.9% vs. 43.8%, p = 0.0099), but it was unrelated to other demographics, disease diagnosis, health literacy, or food pantry or SNAP use.

Table 2. Current work practices and nutrition-related beliefs, knowledge, confidence, and interest in training among food pantry personnel in Oklahoma, n = 129.

Characteristic	n (%)
Length of service, median (range)	35.5 months (1 month–36 years)
Work responsibilities, % yes
Ordering food	23 (17.8)
Soliciting donations	23 (17.8)
Screening clients for eligibility	51 (39.5)
Preparing food bags	70 (54.3)
Assisting clients with shopping	42 (32.6)
Providing referrals or information	42 (32.6)
Current practice, % regularly
Ask clients if they have been diagnosed with a chronic disease	18 (13.9)
Healthy diet education	11 (9.0)
SNAP referral	24 (19.5)
WIC referral	21 (17.4)
Disease-specific diet education	12 (9.8)
Collection of body weight	2 (1.6)
Beliefs on nutrition-focused services, % agree
Ignoring nutrition needs is unacceptable	109 (87.2)
Providing diabetic friendly foods for diabetics should be part of job	103 (81.1)
Clients willing to listen to healthy eating advice	62 (49.2)
Confidence in delivering nutrition-focused services, % confident
Healthy diet education	57 (45.6)
SNAP referral	76 (60.8)
WIC referral	76 (60.3)
Disease-specific diet education	45 (36.3)
Weight	25 (20.3)
Perceptions about client receptivity to nutrition, % agree
Most not interested in changing eating behaviors	77 (63.1)
Most will select fruits and vegetables	101 (80.8)
Most do not know health risks of poor nutrition	73 (58.9)
Personal nutrition knowledge, % agree
Following a healthy diet	79 (63.2)
Perceptions about poor nutrition as a risk factor for disease, % agree
Diabetes risk	124 (97.6)
Heart disease or high blood pressure risk	125 (100.0)
Obesity risk	125 (98.4)
Interest in delivering client services, % yes
Improve diet	87 (68.0)
Prepare groceries	81 (63.3)
Apply for SNAP	65 (50.8)
Interest in training on addressing client health needs at the food pantry
Yes	73 (57.9)
Training preferences, % most preferred
In person at food bank	10 (14.1)
In person at food pantry	32 (45.1)
Webinar	9 (12.7)
Self-guided online training materials	8 (11.3)
Printed materials	12 (16.9)

Knowledge, confidence, and interest in training

Although not statistically significant, more pantry personnel who reported having healthy eating knowledge regularly provided clients with healthy diet education than those who lacked knowledge (12.8% vs. 2.3%; p = 0.0952). Furthermore, those who were confident in delivering healthy diet education were more likely to regularly provide this education to clients than those lacking confidence (16.1% vs. 1.5%; p = 0.0056). Similarly, those who were confident in delivering disease-specific diet education were more likely to regularly provide clients with chronic disease-related diet education than those who lacked confidence in this area (27.3% vs. 0%; p < 0.0001).

Nearly all respondents agreed that nutrition is related to diabetes, heart disease, high blood pressure, and obesity risk (Table 2). However, many personnel thought clients were unaware of the health risks of poor nutrition (58.9%) and were uninterested in changing their eating habits (63.1%); nonetheless, the majority of personnel (80.5%) agreed that most clients would select fruits and vegetables if offered at the food pantry. Overall, more than half (57.9%) of personnel indicated an interest in training to address client health needs. This interest was unrelated to personnel demographics, disease status, health literacy, or food pantry or SNAP use. Among personnel interested in this training, most preferred either in-person training at their pantry or food banks (59.2%) compared to webinars, online, or printed materials. However, almost half of pantry personnel (49.2%) expressed uncertainty regarding clients’ willingness to listen to their advice on healthy eating, but this perception was not associated with personnel interest in health-related training (p = 0.3458).

Food pantry organizations

Among the 109 organizations sampled, 69 completed the organizational survey. The majority of food pantries were affiliated with a religious organization (67.2%), in operation for more than 10 years (71.6%), and open more than 1 day/week (78.3%) (Table 3). While most food pantries used traditional models (55%), one-quarter used choice models (24.6%) and another 20.2% reported using semi-choice. While there was not a statistically significant difference in the number of clients or households served by type of pantry, choice pantries reported serving almost twice as many unduplicated clients per month compared to semi-choice and traditional pantries (737.5 vs. 400 and 300, respectively). Choice models also had more full-time paid staff than other models (p = 0.0143) and were more likely to have refrigeration capacity (p = 0.0319). Most choice pantries had been using the choice model for four years or more (70.6%) and the remaining choice pantries used this model for 1–3 years (29.4%), while most semi-choice pantries had been using that model for less than 1 year (58.3%), another one-third (33.3%) had been using the semi-choice model for 1–3 years.

The majority of organizations had cold storage capacity. Interestingly, fewer pantries had refrigeration capacity (87.9%) than freezer capacity (95.5%). The proportion of pantries with refrigeration differed by pantry model with all choice (100%), the majority of traditional (88.9%), and less semi-choice (69.2%) pantries reporting refrigeration capacity (p = 0.0319).

Nutrition-related policies and practices

No organizations reported collection of weight data, while a few (8.7%) collected health-related information. Although not significantly different, more choice (17.6%) and semi-choice (14.3%) pantries collect health-related data than traditional (2.6%) pantries (p = 0.0798). Food allergies were also documented by 13% organizations. Only about a quarter of organizations reported using client data to inform food ordering (23.2%) or service planning (27.5%).

Very few organizations (4.5%) had written nutrition policies, but more reported referencing either MyPlate (32.1%) or Foods to Encourage nutrition guidelines (17.9%) and one-quarter (25.8%) reported accessing the Hunger and Health website (Table 4). Few organizational respondents perceived that their clients would be interested in receiving nutrition education (13.2%), and this perception did not vary by food pantry model type. Moreover, less than one in five food pantries (17.6%) distributed health education materials to clients. However, significantly more choice pantries (47.1%) distributed educational materials compared to semi-choice (0%) and traditional models (10.5%) (p = 0.0011). Similarly, although few pantries (14.7%) reported using dietetic interns, a greater proportion of choice pantries (41.2%) used them than semi-choice (15.4%) and traditional model pantries (2.6%) (p = 0.0007). In addition, few pantries (11.8%) reported offering onsite nutrition workshops for clients, with a greater proportion of choice pantries (35.5%) offering workshops than semi-choice (7.7%) and traditional model pantries (2.6%) (p = 0.0020).

Table 3. Operational characteristics of food pantry organizations in Oklahoma, n = 69.

Characteristic	Total n (%)	Traditional, n = 38	Semi-choice, n = 14	Choice, n = 17	p Value
Affiliation
Religious	45 (67.2)	25 (69.4)	11 (78.6)	9 (52.9)	0.2908^b
Years open, median (range)	16 (0.5–60)	12	18	27.5	0.0941
Open ≥1× per week, % yes	54 (78.3)	27 (71.1)	12 (85.7)	15 (88.2)	0.3610^a
Households served/month, median (range)	138 (2–1700)	102.5	143	278	0.1318
Unduplicated clients served/month, median (range)	400 (2–5800)	300	400	737.5	0.0785
Staffing, median (range)
Full-time paid staff	0 (0–45)	0	1	2	0.0143
Part-time paid staff	2 (0–35)	1	1	2	0.2060
Volunteers	12 (0–130)	6.5	17.5	15.5	0.3872
Refrigerated storage capacity
Has refrigeration	58 (87.9)	32 (88.9)	9 (69.2)	17 (100.0)	0.0319^a
Freezer storage capacity
Has freezer	64 (95.5)	35 (94.6)	12 (92.3)	17 (100.0)	0.7637^a

^aFisher’s exact test.

^bChi-square test.

Bold value denotes p-value significance less than 0.05

Table 4. Nutrition-focused practices, availability of healthy foods, and perceived client interest in nutrition among food pantry organizations in Oklahoma, n = 69.

Characteristic	Total n (%)	Traditional, n = 38	Semi-choice, n = 14	Choice, n = 17	p Value
Nutrition-related practices
Nutrition policies and resources
Written nutrition policy	3 (4.5)	3 (8.1)	0 (0.0)	0 (0.0)	0.4122^a
MyPlate guidelines	9 (32.1)	3 (20.0)	0 (0.0)	6 (54.5)	0.1473^a
Foods to encourage guidelines	5 (17.9)	3 (20.0)	0 (0.0)	2 (18.2)	1.0000^a
Food safety guidelines	18 (64.3)	9 (60.0)	1 (50.0)	8 (72.7)	0.8490^a
Accesses hunger + health website	17 (25.8)	8 (21.6)	5 (38.5)	4 (25.0)	0.5486^a
On-site services
SNAP referrals	8 (11.9)	2 (5.4)	1 (7.7)	5 (29.4)	0.0464^a
Medical clinic	7 (10.5)	3 (8.1)	1 (7.7)	3 (17.7)	0.5595^a
Other client engagement efforts
Nutrition ed. materials	12 (17.6)	4 (10.5)	0 (0.0)	8 (47.1)	0.0011^a
Uses dietitians or interns	10 (14.7)	1 (2.6)	2 (15.4)	7 (41.2)	0.0007^a
Nutrition workshops	8 (11.9)	1 (2.6)	1 (7.7)	6 (35.3)	0.0020^a
Availability of healthy foods
Distribution of fresh produce
>6 months	51 (77.3)	25 (69.4)	10 (76.9)	16 (94.1)	0.2661^a
<6 months	3 (4.6)	2 (5.6)	0 (0.0)	1 (5.9)
Planning to start within next 6 months	3 (4.6)	3 (8.3)	0 (0.00)	0 (0.0)
Not planning to distribute	9 (13.6)	6 (16.7)	3 (23.1)	0 (0.0)
Healthy food availability, % regularly
Fresh fruit	16 (23.5)	4 (10.5)	3 (23.1)	9 (52.9)	0.0032^a
Fresh vegetables	21 (30.9)	8 (21.1)	3 (23.1)	10 (58.8)	0.0157^b
Canned vegetables, no salt	11 (16.4)	6 (16.2)	2 (15.4)	3 (17.6)	1.0000^a
Canned fruit, lower sugar	10 (14.7)	4 (10.5)	1 (7.7)	5 (29.4)	0.1684^a
Frozen vegetables	5 (7.6)	0 (0.0)	0 (0.0)	5 (29.4)	0.0008^a
Frozen fruit	4 (5.9)	0 (0.0)	0 (0.0)	4 (23.5)	0.0038^a
Eggs	8 (11.8)	3 (7.9)	1 (7.7)	4 (23.5)	0.2627^a
Nuts/Seeds	2 (2.9)	1 (2.6)	0 (0.0)	1 (5.9)	0.6914^a
Beans	37 (55.2)	17 (45.9)	7 (53.8)	13 (76.5)	0.1107^b
Milk alternatives	2 (2.9)	2 (5.3)	0 (0.0)	0 (0.0)	1.0000^a
Perceived client receptivity, % very interested
Healthier foods	15 (22.1)	8 (21.1)	2 (15.4)	5 (29.4)	0.6752^a
Nutrition education	9 (13.2)	6 (15.8)	0 (0.0)	3 (17.6)	0.3384^a

^aFisher’s exact test. ^bChi-square test.

Bold value denotes p-value significance less than 0.05

Healthy food inventory and distribution

Nearly one-quarter of organizational respondents (22.1%) perceived that their client population would be interested in receiving healthier foods (Table 4). Over three-quarters of food pantries reported distribution of fresh produce for longer than 6 months (77.3%); however, pantries reported that produce was not consistently available for distribution with only 23.5% of pantries having fresh fruits regularly available. A greater proportion of choice pantries (52.9%) regularly had fresh fruits compared to semi-choice (23.1%) or traditional (10.5%) (p = 0.0032). Similarly, less than one-third (30.9%) of pantries reported having fresh vegetables regularly available with a greater proportion of choice pantries (58.8%) regularly having fresh vegetables compared to semi-choice (23.1%) or traditional (21.1%) (p = 0.0157). Other forms of fruits and vegetables were also infrequently available with less than one in seven (14.7%) pantries regularly having canned fruit in juice or light syrup and less than one in six (16.4%) regularly having low sodium canned vegetables. While not statistically significant, more choice pantries (29.4%) regularly had lower sugar canned fruit compared to semi-choice (7.7%) or traditional (10.5%) pantries (p = 0.1684). Furthermore, few organizations reported having frozen fruit (5.9%) or frozen vegetables (7.6%), regularly available and these were only available at choice pantries. Furthermore, eggs (11.8%), nuts/seeds (2.9%), and milk alternatives (2.9%) were infrequently available but availability of these items did not differ by pantry type. On the contrary, beans were regularly available (55.2%) at all pantry types.

Most pantries across all three pantry types wanted additional healthy food items, including the majority wanting more fresh fruit (69.7%), fresh vegetables (69.2%), nuts/seeds (67.7%), lean protein (68.2%), whole grains (53.1%), dairy (65.6%), milk alternatives (54.5%), and eggs (66.7%) in their food inventory. The desire for these items did not significantly vary by pantry type.

Discussion

This study found that more than two-thirds of volunteers and staff working in Oklahoma food pantries are interested in delivering nutrition-focused services, but more than half lack confidence and would like to receive training in this area. However, far fewer personnel regularly provide nutrition education or other related activities when interacting with clients. Similarly, few organizations had formalized any nutrition-focused food pantry practices, including operational activities related to healthy food procurement, nutrition education, and related initiatives. These findings, when applied to previous work identifying high rates of diabetes and hypertension among households accessing food pantries,¹ suggest that food pantries may be high-reach settings for the delivery of health promotion programs, but additional resources are likely needed to initiate systems-level adoption, implementation, and maintenance of these interventions.

Interestingly, our study indicates that some degree of organizational flexibility exists within Oklahoma’s food pantry network, as demonstrated by the proportion of choice and semi-choice pantries reporting a recent transition to these models. Nonetheless, the majority of food pantry organizations in this study reported a traditional service model, which was found to be associated with a lower likelihood of distributing client nutrition education and healthy food availability. Since food environments are associated with dietary intake,³¹ these findings contribute to evidence that choice pantries may be more supportive of healthy behaviors among clients. However, longitudinal studies are needed to confirm whether a transition from traditional to choice pantry leads to healthier food inventories for reasons such as increased client demand for healthy foods, or whether there are other factors associated with both choice pantries and offering healthy foods. Additionally, despite the wide availability of refrigerator and freezer capacity reported by agencies, far fewer organizations reported regular availability of fresh and frozen produce. This finding contradicts perceptions by food banking executives that lack of cold storage is a primary barrier to food pantry distribution of fresh fruits and vegetables.³² Furthermore, the majority of organizations reported difficulty obtaining other healthy foods for regular distribution to clients. These findings indicate that additional resources or procurement strategies may be needed for healthier food distribution in food pantries. More studies are needed on the systematic barriers related to the procurement and distribution of fresh produce and other healthy foods that concurrently include perspectives from food banks and their associated partner agencies.

The characteristics of personnel in our study indicate existing food pantry workforce may be ideal for delivering nutrition education or other health-related pantry services, if provided with the proper training. Lay community health workers have been used in a variety of primary and community-based health-care settings for the delivery of disease prevention and self-management programs with the added advantage of peer support.^33–35 Our study found that the majority of food pantry personnel have adequate health literacy and many have a personal history of food assistance program use and/or a diagnosis with diabetes or hypertension, which makes these individuals ideal candidates for a similar peer support role in food pantry-based health programs. Furthermore, food bank-sponsored trainings for food pantry workers on health-related topics may be a natural extension for many food banks that have traditionally offered pantry personnel training programs, primarily on the topics of food safety^36–38 or building agency capacity,^36–39 though some provide nutrition education and healthful food stocking strategies to personnel.^40,41

Personnel in this study overwhelmingly preferred training at their food pantry, and train-the-trainer models align with these learning preferences, where a single professional nutrition educator employed by the food bank trains food pantry personnel to provide health and nutrition education.⁴² In contrast, existing online resources available on Feeding America’s Hunger and Health website intended for use among food bank and food pantry personnel,³⁰ as well as others developed for WIC⁴³ and SNAP-Ed⁴⁴ staff that could also be adapted for the education of food pantry workers, may not align with personnel learning needs identified in this study. Webinars and self-guided online training materials were the least preferred forms of training among participants; therefore, additional dissemination strategies may be needed to maximize use of the assets available on these existing technical assistance websites. The infrequent utilization of dietitians and dietetic interns among food pantries in this study also highlights opportunities for food banks to collaborate with state dietetic associations and dietetic internship programs. Such partnerships could facilitate the delivery of professional nutrition services at food pantries, building on other models that provide food pantries with trained nutrition educators to perform direct client nutrition education at agencies.^45,46

This study has several limitations. First, this study was conducted in one state with a representative sample of pantry organizations in eastern Oklahoma and FRCs in western Oklahoma, which may not be representative of personnel or food pantry organizations elsewhere. Nationally, an estimated 6.6% of food pantry volunteers are under the age of 18,¹ and personnel in this age-group were excluded from the current study. However, the median age of our sample was 61 years, which is comparable to other national studies that indicate 41.4% of personnel are 60 and older.¹ Finally, temporality between choice models and nutrition-focused food pantry practices cannot be established due to the cross-sectional nature of this study.

Conclusion

Food pantries serve populations with higher rates of nutrition-related chronic disease,^1,3,4 and these settings may be opportune locations for the delivery of services and programs that promote healthy eating for hard-to-reach populations. This study’s findings show that although most food pantry personnel are receptive to training on how to deliver nutrition-focused pantry services and also believe that food pantries should address clients’ nutritional needs, current food pantry organizational resources are lacking. Food pantries may benefit from in-person workforce training, other forms of technical assistance, and additional resources to obtain and distribute healthier foods to more adequately address the nutritional needs of the clients they serve.

Declaration of interest

None. Authorship: M.S.W. developed the research aims addressed in the paper, contributed to each section of the paper, and synthesized the final manuscript. M.B.W. led the methods developed for the FISH Study and contributed to the methods and results sections of the manuscript. K.E.C. conducted the primary literature review and contributed to introduction and discussion sections. J.L. analyzed data. J.I.V. and D.J.V. contributed to overall conceptualization and design of the FISH study and edited the manuscript.

Acknowledgments

The authors would like to thank the Community Food Bank of Eastern Oklahoma and the Regional Food Bank of Oklahoma for their collaboration in the development and implementation of the Food Independence, Security, and Health (FISH) study. We especially thank Emma Horton, Summer Frank, and Daryl Geller for their contributions in survey development, Charlotte Love for her assistance in data collection, and Ellen Pogemiller, Katie Fitzgerald, Eileen Bradshaw, Cindy Cummins, and Phyllis Holmes for their ongoing involvement in the FISH Study.

Additional information

Funding

Partial funding for this study was provided by the Oklahoma Tobacco Settlement Endowment Trust through a grant to the Oklahoma Tobacco Research Center [092-016-0002; PI: JI Vidrine].

Notes on contributors

Marianna S. Wetherill

Marianna S. Wetherill, PhD, MPH, RDN-AP/LD, is the George Kaiser Family Foundation Chair in Population Health and assistant professor of Health Promotion Sciences at the University of Oklahoma College of Public Health and assistant professor of Family and Community Medicine at the OU-TU School of Community Medicine.

Mary B. Williams

Mary B. Williams, PhD, is the George Kaiser Family Foundation Chair in Public Health Biostatistics and assistant professor of Epidemiology at the University of Oklahoma College of Public Health and assistant professor of Family and Community Medicine at the OU-TU School of Community Medicine.

Kayla Castleberry White

Kayla Castleberry White, MPH, is a research assistant at the University of Oklahoma College of Public Health and a dietetic intern at Texas Tech University.

Ji Li

Ji Li, MS, is a research biostatistician in the Biostatistics and Epidemiology Research Design and Analysis Center in the Department of Biostatistics and Epidemiology at the University of Oklahoma College of Public Health.

Jennifer I. Vidrine

Jennifer I. Vidrine, PhD, is the Peggy and Charles Stephenson Endowed Chair in Cancer, associate director for Cancer Prevention and Control at the Stephenson Cancer Center, director of the Oklahoma Tobacco Research Center at the Stephenson Cancer Center, and an associate professor in the Department of Family and Preventive Medicine within the College of Medicine at the University of Oklahoma Health Sciences Center.

Damon J. Vidrine

Damon J. Vidrine, MS, DrPH, is the program coleader for Cancer Prevention and Control at the Stephenson Cancer Center, associate director of Research at the Oklahoma Tobacco Research Center, and associate professor in the Department of Family and Preventive Medicine within the College of Medicine at the University of Oklahoma Health Sciences Center.