3. 3
ACKNOWLEDGEMENTS
We would like to thank the Boston Public Health Commission’s Chronic Disease Prevention and Control
Division for their interest in collaborating with Boston University School of Public Health this semester.
We appreciate your encouragement and passion for a project that holds such high public health
significance, and we are grateful for the opportunity to improve our skills as public health practitioners.
A special thanks to the following people: Anne McHugh, Maura Ackerman, Mary Bovenzi, Nicole Ferraro,
and Felipe Ruiz.
Secondly, we would like to thank our stakeholders for providing insight into this vulnerable population,
as well as sharing with us their efforts to address and access this population: Parke Wilde, Jennifer
Obadia, Fredi Shonkoff, Ronn Garry Jr., Frank Martinez Nocito, Stephanie Ettinger de Cuba, Sutton
Kiplinger,andEmilyShea.
Finally, the MC802 teaching team deserves our gratitude and recognition for their coaching, inspiration,
and leadership. Thank you to Lois McCloskey, Joan Bragar, and Colbey Ricklefs for making this a truly
rewardinglearningexperience forusall.
4. 4
EXECUTIVE SUMMARY
Many programs exist in Boston to help low-income residents meet their basic needs, which include
access to nutritious food. These include federal food assistance programs, such as SNAP, WIC, and TANF.
Our project focuses specifically on gaps in SNAP eligibility and coverage that prevent low-income Boston
residents fromaccessinghealthyfoods.
Although food assistance programs such as SNAP are meant to help those most in need, they neglect to
provide assistance to vulnerable populations that may have gross monthly incomes that are above the
defined cutoff. The federal standards incorrectly assume that the cost of living is the same across the
entire U.S., and do not take into account the high cost of living in cities such as Boston. This effectively
disqualifies someone with an ostensibly higher income from accessing food assistance services that they
need. Due to the high cost of living, a significant portion of Boston’s population falls into a “threshold”
income category, meaning they earn too much to participate in SNAP and other federal and state food
assistance programs,yetstill struggle toputfoodonthe table.
BPHC has created the term “threshold population” for those who do not have reliable access to
affordable and nutritious food in the city of Boston, but whose income level is too high to qualify for
federal nutrition assistance programs. One of the Chronic Disease Prevention and Control Division’s
ultimate goals is to design targeted programs to improve rates of food security among the threshold
population, and the objective of our project has been to provide BPHC with the information they need
to begintargetingresourcestowardthisuniqueanddiversepopulation.
This semester, we worked as a team to develop a way to quantify, track, and target the threshold
population. To do this, we conducted an in-depth literature review of existing peer-reviewed journals
and grey literature concerning best practices that target this population. Additionally, we conducted
stakeholder interviews with experts in the food access field to assess the extent of the threshold
populationprobleminBoston.
Our research led us to develop a Composite Index, which pools together data from several food
insecurity databases in Boston, including the Children’s Health Watch (CHW)/Hunger Vital Sign (HVS)
data, the BMC Food Pantry data, the Greater Boston Food Bank (GBFB) data, and the Project Bread
FoodSource Hotline data. This tool also considers certain criteria which act as indicators for the
threshold population, including livable wage status, food assistance status, and housing cost burden.
This Composite Index acts as a conceptual framework that BPHC can utilize to develop a system to
identifyandtrackthe thresholdpopulation inBoston.
Our goal is that BPHC utilizes our findings from the stakeholder analysis and literature review to
implement the Composite Index. We hope that BPHC can use our proposal to identify and target the
thresholdpopulation inBoston.
5. 5
TABLEOF CONTENTS
I. BACKGROUND AND SIGNFICANCE........................................................................................6
Organizational Context........................................................................................................6
The Challenge.....................................................................................................................6
Project Methods.................................................................................................................7
Scope of the Problem..........................................................................................................7
Existing Food Insecurity Solutions in Boston .........................................................................8
II. LITERATURE REVIEW RESULTS.............................................................................................9
Best Practices: Screening Tools............................................................................................9
Best Practices: Citywide Initiatives.......................................................................................9
III. STAKEHOLDER ANALYSIS.................................................................................................10
Potential Target Populations .............................................................................................10
Use of Screening Tools and Composite Index......................................................................10
Food Insecurity Root Causes..............................................................................................10
Database and Criteria Recommendations...........................................................................11
Overall Insights.................................................................................................................11
Conclusions from Literature Review and Stakeholder Analysis.............................................12
IV. COMPOSITE INDEX..........................................................................................................12
Databases........................................................................................................................13
Threshold Criteria.............................................................................................................14
V. MOVING FORWARD.........................................................................................................17
Implementation................................................................................................................17
Monitoring and Evaluation................................................................................................17
VI. RECOMMENDATIONS AND NEXT STEPS ...........................................................................17
VII. REFERENCES...................................................................................................................19
VIII. APPENDIX.....................................................................................................................22
6. 6
I. BACKGROUND AND SIGNFICANCE
Organizational Context
Our project sits within the Community Initiatives Bureau (CIB) of BPHC. The CIB is committed to
addressing environmental health concerns, preventing and managing Boston’s chronic disease burden,
enforcing and regulating citywide health ordinances, and improving access to health care for Bostonians.
Within the CIB, we worked specifically with the Chronic Disease Prevention and Control Division. The
Division is dedicated to reducing Boston’s burden of chronic diseases, such as heart disease, diabetes,
and cancer. The Division addresses disparities in health outcomes, treatment, and related services while
improving the wellbeing of Boston’s most vulnerable residents (1). In the past, the Division has
implemented health-promoting programs, including nutritional education campaigns, programs to
increase physical activity,andcancerscreeninginitiatives. (SeeAppendix A forEnvironmentalScan).
The Challenge
Many programs exist in Boston to help low-income residents meet their basic needs, including access to
nutritious food. These include federal food assistance programs, such as SNAP, WIC, and TANF. Our
project focuses specifically on the gaps in SNAP eligibility and coverage that prevent low-income Boston
residentsfromaccessinghealthyfoods. (SeeAppendix CfortheChallengeModel).
To qualify for SNAP benefits, individuals and households must meet strict income guidelines. The federal
income limit is “a gross monthly income that is at or below 133% of the federal poverty line” (2). This
means a single-person household cannot receive benefits if an individual’s gross monthly income is
greater than $1,276. Table 1 below illustrates the federal definition of 133% of poverty for households
of differentsizes.
Table 1: Federal Definitionof133% ofpoverty (2)
HouseholdSize Grossmonthly income
(130% of poverty)
Netmonthly income
(100% of poverty)
1 $1,276 $ 981
2 1,726 1,328
3 2,177 1,675
4 2,628 2,021
5 3,078 2,368
6 3,529 2,715
7 3,980 3,061
8 4,430 3,408
Each additional member +451 +347
Although food assistance programs such as SNAP are meant to help those most in need, they neglect to
provide assistance to vulnerable populations that may have gross monthly incomes that are above the
defined cutoff. The federal standards incorrectly assume that the cost of living is the same across the
entire U.S., and do not take into account the high cost of living in cities such as Boston. This effectively
disqualifies someone with an ostensibly higher income from accessing food assistance services that they
need. In Boston, the livable wage for a single-person household is $13.77 an hour, or a gross monthly
income of $2,203 (3). In order for an individual to live comfortably and cover all basic needs in Boston
(i.e. food, housing, healthcare), he/she would need to earn nearly $1,000 more per month than the
7. 7
amount designated by the SNAP eligibility criteria. Due to the high cost of living, a significant portion of
Boston’s population falls into a “threshold” income category, meaning they earn too much to participate
inSNAPand otherfederal andstate foodassistance programs,yetstill struggle toputfoodonthe table.
BPHC has created the term “threshold population” for those who do not have reliable access to
affordable and nutritious food in the city of Boston, but whose income level is too high to qualify for
federal nutrition assistance programs. The Commission’s ultimate goal is to design targeted programs to
improve rates of food security among the threshold population. In order to this, BPHC tasked us to
determine:
What is the scope of the threshold population problem? How do we quantify the need for
targetedinitiatives?
How can BPHC and its partners create initiatives to support the threshold population,
particularlyaroundprovidingaccesstohealthy,affordable,andculturallyappropriatefood?
Are there existing supports for this population in Boston? How well are these services and
programsutilized?
What are the bestpracticesand recommendations movingforward?
Project Methods
In order to determine a way to identify the threshold population in Boston, we conducted an in-depth
literature review of peer-reviewed articles, national and state databases and reports, and grey
literature. We simultaneously conduced stakeholder interviews with prominent members of the food
access community in Boston. BPHC provided us with a list of initial contacts and we used a snowball
methodtoask intervieweesforreferrals of otherpotential stakeholders.
Scope of the Problem
Nationally, 26% of food-insecure individuals are above 185% of the poverty line, making them ineligible
for most food assistance programs. The issue is wide reaching, affecting individuals, single parents, large
families, and elderly and disabled persons (4). Throughout the country, people share stories of their
struggle onthe Internet,askingforadvice andassistance.
“I was on food stamps, got a dollar raise and made 40 over the gross. I left there crying,
wondering how I was going to feed my kids. I had no home phone, no cell phone, no cable,
living at the very minimal…They really need to reform the program…I wonder how they get
their figureson whatAmericanscan really live off of?”(5)
“Recently, I tried to get food stamps and they said I made too much. I work 40 hours a week
and get paid $10.00 an hour. I am not even close to rich and more on the struggling side. I just
am curious how they can figure I made too much? If I wasn't trying my hardest and just didn't
have a job would they be more willing to help me if I was unmotivated? The people I see that
can work, but choose not to seem to always be able to get the help they need. I am not trying
to scamthe systematall. Justa hard-workingmother...any suggestions?”(6)
Massachusetts is not immune to the problem. High rates of food insecurity persist in our state, despite
the fact that 11.8% of Massachusetts’ residents are enrolled in SNAP (7). In 2013, there were 375,695
food insecure households in Massachusetts, which accounts for 10.6% of total Massachusetts’
households (7). The rate of food insecurity iseven higher in Boston. In 2014, 14.5% of randomly sampled
households in Boston reported that they did not have enough money to buy food at least once over the
course of a year (8). 1 in 12 individuals in eastern MA access food from Greater Boston Food Bank and
8. 8
its member agencies annually (4). According to Feeding America data, 15.8% of Suffolk county
householdsand18.1%of Suffolkcountychildrenare foodinsecure (9).
Prohibitive food pricing may partially explain this problem. The Initiative for a Competitive Inner City
(ICIC) compared the prices of six basic food items in Roxbury and Back Bay. Roxbury represents the low-
income end of Boston’s spectrum, with a median income of $28,000. Back Bay, on the other hand, has a
median household income of $86,000. The ICIC found that many of the six basic food items were more
expensive inRoxburythantheywere inBackBay(see Table 2) (10).
Table 2: Comparison of Food Pricesin Back Bay and Roxbury (10)
FoodItem Back Bay GroceryStore Roxbury GroceryStore
Gallon of Milk $4.49 $4.99
Chicken Soup $1.39 $1.25
Loaf of Bread $1.39 $1.29
Iceberg Lettuce $1.69 $1.99
Chicken Breast $5.99/lb $6.99/lb
Infant Formula $1.17/oz $1.21/oz
Existing Food Insecurity Solutions in Boston
It is clear that federal assistance is not a comprehensive solution to foodinsecurity in Boston. To address
the gaps, BPHC and other Boston partners have implemented food access initiatives, such as Bounty
Bucks (BB). BPHC created BB to financially incentivize Boston residents to use SNAP credit at farmers’
markets to increase city-wide consumption of fruits and vegetables. The BB program matches each
SNAP dollar spent at farmers’ markets, up to $10. This means that for $10 SNAP dollars, customers can
buy$20 worthof produce.
The BB program has been fairly successful and has grown significantly since its implementation in 2008.
During the 2013 to 2014 season, 21 farmers’ markets enrolled in the BB program, and a total of
$166,540 BB dollarswere used(11). Analysis of the BB programhas found(11):
An increase in vegetable consumption: SNAP clients who shop at farmers’ markets consume 0.5
more vegetablesthanSNAPclientswhodonot.
An incentive for new shoppers at farmers’ markets: 70% of BB farmers’ market shoppers said
that the program makesfarmers’marketsmore appealing.
Females and those who are more educated (completed college or graduate degree programs)
are more likelytoutilize the BountyBucksprogram.
While the Bounty Bucks program has been successful, it is not an effective year-round solution
due to Boston’sclimate andlimitedwinterfarmers’markets.
There are many other programs in Boston that strive to improve food security. They include the Greater
Boston Food Bank, the Healthy Corner Store Initiative, and the Healthy Food Prescription Program, to
name a few (12). Although these initiatives help to address a portion of the problem, they do not
9. 9
specifically provide solutions for the threshold population. We sought out to define this population so
that BPHC andits partnerscouldcreate a targetedapproachin the future.
II. LITERATURE REVIEW RESULTS
Best Practices: Screening Tools
The WE CARE screening tool is a questionnaire used in Philadelphia hospitals to assess families’ needs
for childcare, housing, employment, education, food security, and heat during well-child visits (13). This
low-cost screener is a holistic approach to linking families with a multiplicity of needs to existing
community resources. Mothers who screened positive for the WE CARE tool were more likely than
mothers who attended the non-WE CARE implementing community health centers to enroll in a new
"community resource" at the 12-month visit. At the 12-month visit, mothers at the WE CARE clinics were
more likely to be employed, had an increased likelihood of having child care for their children, and had a
lower likelihood of living in a homeless shelter (13). This screening tool is a low-cost, holistic method
that links needy families to existing community resources, and improves their utilization rates. This tool
is a best practice because it goes beyond just screening for food insecurity, but rather gains insight into
the whole individual and acknowledges his/her multiple basic needs that are necessary to survive and
thrive (seeAppendix BforCompleteLiterature Review).
Children’s Health Watch developed a similar tool, the Hunger Vital Sign, to increase utilization of existing
community resources in Boston and Beverly, Massachusetts. It is a two-question screener that assesses
food insecurity in clinical settings (14). In Beverly, patients are referred to the Prescription Food Bag
program and are given resources about SNAP and food pantry services. In Boston, patients are identified
as food insecure and are referred to BMC’s Preventative Food Pantry. This tool facilitates the
identification of children and families who may need food assistance (14). Similar to the WE CARE tool,
this screener aims to increase utilization of existing community resources and takes a holistic approach
to resolvingfoodinsecurity.
Best Practices: Citywide Initiatives
Philly Food Finderis a website created by Philadelphia’s Anti-Hunger Subcommittee. It is a food resource
toolkit that provides Philadelphians with consolidated information about how to get affordable, healthy
food (15). The purpose of the toolkit is to increase utilization of the many existing food resources in
Philadelphia. It was created to assist the 180,000 individuals who qualify for SNAP but are not
participating in the program (15). These individuals fall within our definition of the threshold population.
The website also provides detailed information on applying for SNAP and other nutrition assistance
programsto helplow-incomefamiliesbuyfoodatthe grocerystore.
The Baltimarket Programs were developed by the Baltimore City Department of Health in partnership
with the Baltimore Food Policy Initiative. The initiative includes an interactive website, where residents
can find food resources and SNAP application material. It also includes a virtual supermarket, where
residents can order groceries at libraries or public housing and pick them up at accessible locations. The
virtual supermarket includes a financial incentive where participants receive a $10 bonus to spend on
healthy foods when they shop for the first time and a $10 bonus on six holidays throughout the year
(16).
10. 10
A shopper marketing nutrition intervention was implemented in various supermarkets throughout cities
in Texas and New Mexico. The intervention used social norms marketing theory to increase produce
spending without increasing overall spending. Placards were placed on grocery carts with indicators of
the average amount of fruits and vegetables consumed at that market. This intervention resulted in a
12.4% increase inproduce spendingwithout anincrease inoverall spending(39).
III. STAKEHOLDER ANALYSIS
We conducted stakeholder interviews with eight individuals involved in government, academia, and
community initiatives. We interviewed those with a deep interest in and knowledge of food insecurity in
Boston (see Appendix D for List of Persons Contacted). Our interviews provided us with a variety of
perspectives and revealed potential threshold populations, root causes of food insecurity, and insights
into how to address Boston’s threshold population. Over the course of these interviews, our project and
interview questions evolved (see Appendix D1 for Stakeholder Interview Questions). We extrapolated
recurring themesfrom these interviews to develop our proposal for a Composite Index (see Appendix D2
forStakeholderAnalysisTable,Appendix EforCompositeIndex).
Potential Target Populations
All sectors agreed that those who apply for SNAP, but are denied or are not receiving full benefits are a
key part of the threshold population. Government and academia stakeholders confirmed that seniors,
undocumented immigrants, and the low-income working class fall within the threshold. Several
stakeholders also included refugees, formerly incarcerated, and seasonal workers in their definition of
the threshold.
Use of Screening Tools and Composite Index
We discussed the idea of screening patients for food insecurity in primary care and emergency
department settings with our stakeholders. Many reinforced the idea of using existing screening tools
(i.e. Hunger Vital Sign) to identify the threshold population in Boston. In general, stakeholders thought
that the Composite Index was a worthwhile way to capture the wide-range of population groups that
comprise the threshold.
Food Insecurity Root Causes
Seven out of eight stakeholders emphasized the complex relationship between poverty and food
insecurity. Most agreed that the issue is not the availability of food, as there are many food access
initiatives in Boston. Instead, stakeholders pointed to the low wages plaguing many Boston residents.
We gathered that people simply are not making enough money to afford food for themselves and their
family. Many people working low wage jobs make the decision between buying food and other essential
livelihood costs (i.e. rent, heat, transportation). Stakeholders stressed that wage and income must be
taken into account in order to address the issue of the threshold populations. Academia stakeholders
also mentioned geographic proximity to resources and food outlets as a root cause of food insecurity.
Although geographical access contributes to one’s food security status, it was a consensus that without
11. 11
an increase in wages, changing one’s proximity to food outlets is an ineffective strategy for reducing
foodinsecurity.
Database and Criteria Recommendations
Once we decided to create a Composite Index, we asked our stakeholders to recommend databases that
might include information about the threshold population. Stakeholders in academia recommended the
Project Bread FoodSource Hotline, the Greater Boston Food Bank and Children’s Health Watch/ Hunger
Vital Sign as additional sources of data. Due to recurring recommendations,we chose to include these in
our Composite Index,alongwiththe BMCFoodPantry.
We were able to come up with criteria to determine threshold eligibility from the stated databases. Our
academic stakeholders pointed us to several resources for threshold criteria that would be applicable to
Boston. We settled on three main inclusion levels that include: livable wage through the MIT Living
Wage Calculator, affordable housing according to the Housing Cost Burden, and food assistance status
accordingto DTA data of deniedandrejectedapplicants.
Overall Insights
Our stakeholders shared information vital to achieving BPHC’s mission to reduce food insecurity among
the thresholdpopulation. Overall insightsincluded:
“Name the problem before you can solve it.” It was a consensus that the priority must be to define
the threshold.
“One of my employees got pregnant and even with our insurance couldn’t afford the baby, but if she
quit her job then she would get money from the government.” This statement from a local employer
alludes to his employees’ struggle with the difficult decision to keep their job or opt for
unemployment assistance as a way to make ends meet. All stakeholders supported financially
incentivizingthe workingpopulation.
A stakeholderidentifiedwomenworkinglow wage jobs asanespeciallyvulnerable group.
Several stakeholders referred to changes in Boston’s leadership, which may have shifted focus away
fromfoodaccess. Thismightpose an obstacle toimplementingfoodaccess initiatives inthe future.
Stakeholders in all sectors acknowledged that system changes at the state level affected the SNAP
applicationprocessandbenefitlevelsinrecentyears.
Multiple screening tools are being implemented in different capacities but it is essential to
streamline them in order to reach this ambiguous population. This prompt from our stakeholders
served as a catalyst for us to develop our Composite Index of existing resources to capture the wide-
rangingthresholdpopulation.
“Accessing food resources is important, but often people that can’t afford food also can’t afford
medications, heat, and increasingly rent or mortgage. We need to take a more comprehensive look
at how to make someone economically secure.” Stakeholders agreed that combining anti-poverty
measureswithfoodaccessinitiativesisintegral toaddressingfoodinsecurityamongthe threshold.
12. 12
Table 2: StakeholderInterviewSummaries
Potential
Target Populations
Root Causes of
Food Insecurity
Database and Criteria
Recommendations
Insights
-People who are
denied or ineligible
from SNAP
-Screened patients
in primary careand
ED
-Seniors
-Undocumented
immigrants
-Refugees
-Formerly
incarcerated
-Low income
working class
-Seasonal workers
-Wage/income
-Poverty
-Geographical
location
Databases:
-Project Bread FoodSource
Hotline
-GBFB
-CHW/HVS
-BMC Food Pantry
Criteria:
-LivingWage:
-City ordinance
-133% of poverty line
to living wage
-Housing: HousingCost
Burden
-Food Assistance:DTA
-System changes at the state level affecting benefits/
application process
-SNAP outreach, enrollment, and retention is
necessary
-Pair initiatives to captureall vulnerablepopulations
-Need a clear definition of threshold in order to
access them
-Streamliningscreen tools is essential
-Anti-poverty must be an aspectto address insecurity
among threshold
-Low income working population needs incentiveto
maintain jobs
-Hire within vulnerablecommunities to provide jobs/
economic boost
-Obesity concern as outcome of hunger
-Obstacles includeshiftin gov’t focus
Conclusions from Literature Review and Stakeholder Analysis
Both the literature review and the stakeholder analyses revealed common themes about food insecurity
and the threshold population in Boston, MA. The literature review demonstrated that the need for
addressing the threshold population is great in this community. BPHC would be an early adopter if they
chose to create programs tailored to the threshold population. While certain cities are working to
increase the utilization of existing food access programs and resources, no city is specifically targeting
the threshold population. Several best practices, including the WE CARE screening tool and the Philly
FoodFinderProgram,strive tooptimize utilizationof existingresourcesthroughvariousmethods.
Interviews with several stakeholdersin Boston highlighted the various suggestions to track the threshold
population. We quickly realized that because the threshold population is so diverse, a successful
tracking and identification tool would need to compile from a variety of sources. With this in mind, we
createda conceptual frameworkforour Composite Index.
13. 13
IV. COMPOSITE INDEX
The Composite Index is a tool that can be used long-term to identify and track the threshold population
in Boston. To begin, we illustrated the Composite Index in a conceptual process map (see Appendix E).
To develop this tool, we identified several databases containing information about food insecure
individuals and their families in Boston. For individuals within those databases, we applied criteria to
categorize themaseitherthresholdornotthreshold(seeAppendix E-E5).
Databases
The databases includedinourComposite Index:
1. Children’sHealthWatch(CHW)/HungerVital Sign (HVS)data
2. BMC FoodPantry data
3. GBFB data
4. ProjectBreadFoodSource Hotline data
Children’sHealthWatch/HungerVital Sign
The Children’s HealthWatch/Hunger Vital Sign is a two-question validated food insecurity screener
adapted from the USDA’s 18-item US Food Security Module. It is suitable for assessing food security in
clinical practice (17). The tool identifies families as being very likely food insecure if they answer ‘often
true’or ‘sometimestrue’ toeitherof these twoquestions:
“Within the past 12 months we worried whether our food would run out before we got money
to buymore”
“Within the past 12 months the food we bought just didn’t last and we didn’t have money to get
more”
The CHW/HVS screening tool is currently being used at BMC during well-child and emergency
departmentvisits. All of the datafromthe CHW/HVS isstoredinBMC’s EPIC electronicmedical record.
Boston Medical Center’sFood Pantry
If a provider at BMC diagnoses or identifies an individual as food insecure, they can write the individual a
prescription for the BMC Food Pantry. The prescription and patient utilization of the Food Pantry is
storedin BMC’s EPIC electronicmedicalrecord.
AccessingBMC’S EMR
The stepsBPHC needstotake in orderto access data from BMC’s EMR are (18):
1. Partnering with a researcher at BMC, BUMC, or BUSPH. The clinical researcher would need to get
IRB/HIPPA approval toaccessclinical data(forinformation aboutHIPPA approval– see Appendix E5).
2. Once the protocol has been approved by HIPAA and/or the IRB, researchers and BPHC can access
the data throughthe Clinical DataWarehouse usingthe datarequestform (seeAppendix E3).
3. There is a fee for accessing the Data Warehouse for research purposes (for charges - see Appendix
E4).
4. Once complete, the form and fee should be sent to Linda Rosen (for contact info – see Appendix E1).
Linda is available for any questions or requests or to meet to discuss your particular data needs.
She can assist researchers in the development of identified/de-identified datasets, recurring reports,
webaccessto formattedqueriesandotherdatasets.
GreaterBoston Food Bank
GBFB data consists of results from the Hunger in America (HIA) 2014 Eastern Massachusetts study (19).
GBFB and Feeding America collaborated to develop a comprehensive survey on hunger and food
14. 14
insecurity in Eastern Massachusetts. The study provides aggregate level data on those received food
assistance through the GBFB 2012-2013.
In addition to aggregate prevalence data, individual data may be available. Jonathan Tetrault, Senior
Manager of community initiatives or Adriene Worthington, Senior Manager of Nutrition might have
more information about this (for contact info – see Appendix E1). BPHC can use GBFB’s individual and
population-level datatoidentify thosewhoseek foodassistance fromGBFB’snetworkof 550 agencies.
Project Bread’sFoodSource Hotline
The FoodSource Hotline is a comprehensive Massachusetts-wide information and referral service for
people facing hunger. Hotline counselors refer callers to food resources within their community (e.g.
food pantries, soup kitchens, $2/bag sites, school meals, summer meal sites, elder meals, etc.) (20).
Additionally, counselors screen callers for SNAP eligibility and help them with SNAP applications. Those
who call the Hotline are clearly food insecure. If the Hotline finds that a caller is not eligible for SNAP,
thisindividualispartof the thresholdpopulation.
Although the information in this database is kept confidential, BPHC may be able to access a de-
identified version of the data. Maria Infante of Project Bread may have more information on how to
access this data (for contact info – see Appendix E1). We suggest that BPHC and Project Bread create an
MOU so that BPHC isable to use ProjectBread’svaluable data.
Kid’sCount Data Center
A fifth database that should be considered in the future is the Kid’s Count Data Center. Due to limited
available information, we did not include this in our Composite Index. Kid’s Count is a data center that
collects and compiles indicators to track the wellbeing of children in the United States (21). They have
aggregate Massachusetts state data on the percent of children living in households that were food
insecure atsome pointduringthe year.
Threshold Criteria
The threshold criteriathatwill be includedinthe CompositeIndexare:
1. Livable wage
2. Affordable Housing
3. FoodAssistance
Livable Wage
We considered two ways to define livable wage in Boston. First, we considered basing livable wage off
of MIT’s Living Wage Calculator (sample calculations found in Table 3) (3). According to this definition,
the livable wage is “the hourly rate that an individual must earn to support their family, if they are the
sole provider and are working full-time (2080 hours per year)” (3). Massachusetts’ minimum wage has
increased since MIT developed the calculator; it is now $9.00 per hour, which would slightly change the
values found in Table 3. The poverty rate reflects gross annual income and was converted to an hourly
wage by MIT for the sake of comparison. MIT took the following annual expenses into consideration:
food, childcare, medical, housing, transportation, taxes, and otherexpenses. The values in the table vary
by familysize,composition,andthe family’scurrentlocation bycounty.
15. 15
Table 3: Livable Wage and Annual Expenses(3)
Hourly
Wages
1 Adult 1 Adult
1 Child
1 Adult
2 Children
2 Adults 2 Adults
1 Child
2 Adults 2 Children
LivingWage $13.77 $27.87 $31.95 $10.11 $15.06 $17.32
Poverty
Wage
$5.00 $7.00 $9.00 $3.00 $4.00 $5.00
Minimum
Wage
$8.00 $8.00 $8.00 $8.00 $8.00 $8.00
Annual Expenses 1 Adult 1 Adult
1 Child
1 Adult
2 Children
2 Adults 2 Adults
1 Child
2 Adults
2 Children
Food $3,509 $5,176 $7,786 $6,434 $8,011 $10,339
Child Care $0 $10,125 $13,602 $0 $10,125 $13,602
Medical $2,667 $6,416 $6,204 $5,141 $6,204 $6,268
Housing $12,504 $17,448 $17,448 $13,968 $17,448 $17,448
Transportation $3,764 $6,855 $7,901 $6,855 $7,901 $9,258
Other $2,096 $3,644 $3,987 $3,644 $3,987 $4,819
Required annual
income after taxes
$24,541 $49,664 $56,928 $36,042 $53,676
We considered defining livable wage in based on Boston’s Living Wage Ordinance. The ordinance
assures that employees of city service vendors earn an hourly wage that provides enough for a family of
four to live on or above the federal poverty line. According to this ordinance, Boston city employers
must pay their employees at least $14.11 per hour (22). We decided not to use the Living Wage
Ordinance in our Composite Index because it does not account for family size and composition, unlike
the MIT calculator. While we recommend using MIT’s Living Wage Calculation, it is up to BPHC’s which
metric they would like to use as they move forward with the development of the Composite Index.
Individual and aggregate data sources for BPHC to access individual income data to determine livable
wage include (seeAppendix E2forhowto accessincome data):
Income statisticsfromthe U.S.CensusBureau (23).
SOI (Statistics of Income) Tax Stats. These contain data on a sample of individual income tax
returns (24, 25).
City of Boston Employee Earnings Report, which individual income data for City of Boston
employees (26).
Affordable Housing
Since housing is a substantial expense for many families, particularly in Boston, we selected affordable
housing as our second threshold criterion. According to the US of Housing and Urban Development
(HUD), “families who pay more than 30 percent of their income for housing are considered cost
burdenedandmayhave difficultyaffordingnecessitiessuchas food”(27).
Our Composite Index relies on the Housing Affordability Data System (HADS) to determine those who
are experiencing a high housing cost burden. HADS is publicly available data collected from 2002 and
beyond using the Metro American Housing Survey. The HADS system “categorizes housing units by
affordability and households by income, with respect to the Adjusted Median Income, Fair Market Rent
(FMR), and poverty income….includ[ing] housing cost burden for owner and renter households” (28).
Since thisis publicly available data, BPHC would not need to take any steps to access the HADS database
(seeAppendix E2 forhowto access housing costburden data).
16. 16
Food Assistance
The final criterion determined to affect threshold eligibility is food assistance status. We defined food
assistance as those receiving SNAP, WIC, or TANF benefits. To quantify the threshold, it is important to
identify those who are denied entry into these federal assistance programs. The DTA has data on those
who apply, are accepted, are rejected, and those who lose their benefits for SNAP, WIC, and TANF
beneficiaries.
In order to access this information, BPHC would need to determine the level of data they would require
(aggregate or individual) and any other data sharing limitations. The process for accessing the data
varies based on the level of detail requested. BPHC can access this data by communicating with Frank
Martinez Nocito of the DTA. We recommend BPHC and DTA create a Memorandum of Understanding
(MOU) inorder to facilitate dataexchange (seeAppendix E2forhow to access food assistancedata).
17. 17
V. MOVING FORWARD
Our goal is that BPHC utilizes our findings from the stakeholder analysis and literature review to
implement the Composite Index. We hope that BPHC can use our proposal to identify and target the
threshold population. To assist with the implementation and sustainability of the Composite Index, we
developedamonitoringandevaluationplanfor2015 and beyond(seeAppendix F).
Implementation
In order to implement our Composite Index, we recommend that BPHC create a centralized storage
system to pool data on those who utilize the GBFB, the BMC Food Pantry, the CHW/HVS, and the Project
Bread FoodSource Hotline. Once this data is funneled into a centralized storage system, a BPHC
biostatistician can create an algorithm to select those who are fall into the threshold population. The
algorithm should flag those who do not make a livable wage, have an increased housing burden, and do
not qualify for state and federal food assistance programs. Since the threshold population is so diverse,
it is imperative to include multiple databases and apply the criteria above to best identify the individuals
whofall intothe “threshold”populations.
Monitoring and Evaluation
Our primary monitoring indicator is the number of threshold individuals residing in Boston. This is the
number of food-insecure individuals who are identified using the databases and criteria detailed in our
Composite Index (see Appendix F). We assume that the Composite Index will capture approximately 75%
of the threshold population. Our Index does not take into account all databases that may contain
information on threshold individuals, such as refugee and elderly centers or organizations that assist
formerly incarcerated individuals. More research is needed to determine the best method to access
these additional vulnerable groups.
We recommend that the index be updated biannually to ensure that the Composite Index captures the
threshold. A biannual review of the index will account for the various databases and criteria that update
at different frequencies. For example, the Project Bread FoodSource Hotline is updated daily, while the
Census data that could be used to calculate a livable wage is updated yearly. We hope that the biannual
review will facilitate ease of data sharing between BPHC and the organizations that house these
databases.
Continual monitoring and evaluation of the Composite Index will ensure sustainability in identifying and
tracking the threshold population in Boston over time. Once the databases are accessed and the
algorithm has been developed, the Composite Index will be simple to maintain, provided that BPHC is
able to gain access to the databases on a biannual basis. We believe that no further actions will need to
be taken to be able to identify the threshold population in Boston, and that resources can then be
allocatedtowarddevelopingprogramstoreduce foodinsecuritywithinthispopulation.
VI. RECOMMENDATIONS AND NEXT STEPS
To achieve the Chronic Disease Prevention and Control Division’s vision of increasing the number of
fruits and vegetables consumed per household in Boston, BPHC must specifically target the threshold
population. It is an extremely vulnerable groupin the Boston community. Once the Composite Index has
been implemented, we recommend that a full needs assessment be conducted in key food-insecure
communities of Boston. A needs assessment could be targeted to neighborhoods of Boston that are
federally defined as food deserts, and should also include low-income neighborhoods where many
18. 18
people are not able to make a livable wage. This community assessment will highlight the specific needs
of the food-insecure populations in Boston, and can inform BPHC of next steps in targeting resources for
thispopulation.
Figure 1: Thriving ThresholdsTimeline
Before BPHC channels its resources towards programs for the threshold population, we recommend a
health equity impact assessment be completed. A health equity impact assessment (see Appendix G)
evaluates the logic, capacity, and research of a program or policy and ensures equitable delivery of
programs before they are implemented. We believe that this will allow BPHC to evaluate the equity of
its programs, further tying food access work to the organization’s health equity goals (29). When Boston
Public Health Commission begins its considerations for grant-funded opportunities to target the
thresholdpopulation,referto Appendix Hforfull descriptionsof variousgrantopportunities.
Finally, when BPHC develops programs to target the threshold, we hope that anti-poverty and wage
advocacy work is incorporated into the planning. As it is defined, the threshold population is predicated
on the idea that there are many food-insecure individuals who do not qualify for federal benefits due to
income level. Therefore, BPHC must consider thoroughly analyzing the livable wage gap in Boston and
its implications on food insecurity and healthy food access for residents. By incorporating anti-poverty
initiatives into food systems work at the institutional level, BPHC will be better able to address the root
causesand obstaclesthatthispopulationfaces.
19. 19
VII. REFERENCES
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(3) Livingwage.mit.edu.LivingWage Calculator - LivingWage CalculationforSuffolkCounty,
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buygroceries.[Internet].2015 [cited13 December2015]. Availablefrom:
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(6) Answers.yahoo.com.HowdoImake too muchfor FoodStamps?[Internet].2015 [cited13
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(9) Map the Meal Gap | FeedingAmerica[Internet].FeedingAmerica.2015 [cited2015 Nov 30].
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(10)Icic.org.A GroceryStore inEveryNeighborhood:Boston’sQuesttoEliminateFoodDeserts|
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2015 Nov29]. Availablefrom: http://www.childrenshealthwatch.org/public-policy/hunger-vital-
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(15)PhillyFoodFinder[Internet].PhiladelphiaFoodPolicyAdvisoryCouncil.[cited2015 Nov29].
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(16)Baltimarket- Accessto healthyandaffordable foodsinBaltimore [Internet].Baltimarket.2015 [cited
2015 Dec 1]. Availablefrom: http://www.baltimarket.org/.
(17)Children'sHealthWatch.The HungerVital Sign™ - Children'sHealthWatch[Internet].2015 [cited22
November2015]. Availablefrom: http://www.childrenshealthwatch.org/public-policy/hunger-vital-
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(18)Bumc.bu.edu.Clinical Research –Clinical Warehouse DataAccess» Clinical Research» BUMC
[Internet].2015 [cited20 November2015]. Availablefrom: http://www.bumc.bu.edu/ocr/clinical-
research-clinical-warehouse-data-access/.
(19)GreaterBostonFood BankBlog.Hunger inAmerica2014 – Eastern Massachusetts[Internet].2014
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2014-eastern-massachusetts/.
(20)Projectbread.org.FoodSource Hotline [Internet].2015 [cited24 November2015].Available from:
http://www.projectbread.org/get-help/foodsource-hotline.html.
(21)Datacenter.kidscount.org.KIDSCOUNTData Centerfromthe Annie E.CaseyFoundation[Internet].
2015 [cited20 November2015]. Available from: http://datacenter.kidscount.org/.
(22)Owd.boston.gov.Initiatives|Office of Workforce Development[Internet].2015 [cited10 November
2015]. Available from: http://owd.boston.gov/programs/.
(23)Census.gov.Income Main- PeopleandHouseholds - U.S.CensusBureau[Internet].2015 [cited13
December2015]. Available from: http://www.census.gov/hhes/www/income/.
(24)Irs.gov.SOITax Stats - Individual Income Tax Returns[Internet].2015 [cited13 December2015].
Available from:https://www.irs.gov/uac/SOI-Tax-Stats-Individual-Income-Tax-Returns.
(25)rs.gov.SOITax Stats - IndividualIncome Tax ReturnsPublication1304 (CompleteReport) [Internet].
2015 [cited13 December2015]. Availablefrom: https://www.irs.gov/uac/SOI-Tax-Stats-Individual-
Income-Tax-Returns-Publication-1304-(Complete-Report).
(26)Cityof Boston.Employee EarningsReport2014 | Data | Cityof Boston[Internet].2015 [cited13
December2015]. Available from: https://data.cityofboston.gov/Finance/Employee-Earnings-Report-
2014/4swk-wcg8.
(27)Portal.hud.gov.AffordableHousing - CPD- HUD [Internet].2015 [cited17 November2015].
Available from:
http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/affordablehousing/.
(28)Huduser.gov.AmericanHousingSurvey:HousingAffordabilityDataSystem|HUD USER [Internet].
2015 [cited25 November2015]. Available from:
http://www.huduser.gov/portal/datasets/hads/hads.html
(29)Bphc.org.BlogPosts[Internet].2015 [cited13 December2015]. Available from:
http://www.bphc.org/aboutus/office-director/Pages/Our-Mission-and-Vision.aspx.
(30)ThomasG. Site VisitOne:BPHC communityinitiatives Bureau.Presentationpresentedat;2015;
BostonPublicHealthCommission.
(31)NewYork TimesandCensusBureau’sAmericanCommunitySurvey,“MappingAmerica:EveryCity,
EveryBlock” http://projects.nytimes.com/census/2010/explorer.
(32)What isLogic and Why doesitMatter for Equity?[Internet].[cited 2015 Dec13]. Available
from:http://www.diversitydatakids.org/files/Policy/HeadStart/Capacity/WhatisCapacity.pdf
(33)What isCapacityand Why doesitMatter forEquity?[Internet].[cited 2015 Dec 13]. Available
from:http://www.diversitydatakids.org/files/Policy/HeadStart/Capacity/WhatisCapacity.pdf
(34)What isResearchEvidence andWhyDoesit Matter for Equity?[Internet].[cited 2015 Dec13].
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isResearchEvidence.pdf
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(36)Healthyfoodaccess.org.CommonCapital (HFFI)|healthyfoodaccess.org[Internet].2015 [cited5
October2015]. Available from: http://www.healthyfoodaccess.org/funding/available-
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(37) Nifa.usda.gov.CommunityFoodProjects(CFP) CompetitiveGrantsProgram| National Institute of
Foodand Agriculture [Internet].2015 [cited3 October2015]. Availablefrom:
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(38) Apps.ams.usda.gov.Agricultural MarketingService - CreatingAccesstoHealthy,Affordable Food
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(39)Payne CR,NiculescuM,Just DR, KellyMP.Shoppermarketingnutritioninterventions:Social norms
on grocerycarts increase produce spendingwithoutincreasingshopperbudgets.PrevMedReports
[Internet].2015 [cited2015 Nov29];2:287–91. Available from:
http://www.sciencedirect.com/science/article/pii/S2211335515000443
23. 23
APPENDIX A: ENVIRONMENTAL SCANOF BPHC
ORGANIZATIONALSTRUCTURE OF BPHC
Mission Statement(29)
“To protect, preserve, and promote the health and well-being of all Boston residents,
particularly the most vulnerable.” Public service and access to quality healthcare is the
cornerstone of BPHC’smission.
Vision Statement(29)
“The BPHC envisions a thriving Boston where all residents live healthy, fulfilling lives free of
racism, poverty, violence, and other systems of oppression. All residents will have equitable
opportunitiesandresources,leadingtooptimal healthandwell-being.”
History (29)
BPHC is the country’s first health department. BPHC’s governing Board of Health was started in
1799, with Paul Revere as its first President. When the Board of Health was formed, it focused
on fighting outbreaks of cholera by posting signs around the city and leading a public
information campaign. Two hundred years later, the BPHC has continued the tradition of
prevention by providing the most innovative services for Boston’s residents. In 1996, the BPHC
was formed during the merger of Boston City Hospital and Boston University Hospital. Today, it
isan independentpublicagencyprovidingavarietyof healthservicesand programs.
BPHC Goals (29)
Boston Public Health Commission aims to achieve the following “Health Equity Goals” over the
nextfive years:
● “Reduce the low birth-weight rate among Boston infants and reduce the gap between
the White and BlackLBW rate by 25%.”
● “Reduce obesity/overweight rates among Boston residents and reduce the gap between
White and Black/Latino obesity/overweight rates by 30% for school-aged children and
20% foradults.”
● “Reduce Chlamydia rates among Boston residents 15 through 24 years of age and
reduce the gap in Chlamydia rates between Black, Latino and White residents 15
through24 yearsof age by25%.”
Programs
The Commissionismade upof more than 40 programs within these six bureaus:
● Child,Adolescent&FamilyHealth
● CommunityHealth Initiatives
● HomelessServices
● InfectiousDisease
● AddictionsPrevention
● Treatment& RecoverySupportServices
● EmergencyMedical Services”
24. 24
In total, the bureaus have over 1,100 employees. Our project sits in the Community Initiative
Bureau (CIB), which addresses health issues affecting the entire community of Boston. The
bureau is committed to environmental concerns, chronic disease prevention and management,
the enforcementof citywide ordinances/regulations,andaccesstohealthcare.
Programswithin theCIB
The followingCIBprogramsshare goalssimilartothose of our project:
● Cancer PreventionandManagement
● The HealthConnection
● HealthyEating& Active Living
● CoordinatedSocial Support&Training
● SouthEnd FitnessCenter
● Mayor’s HealthLine
● The OutreachProgram
Key BPHC/CIBLeaders
● BPHC Board of Directors:
○ PaulaA. Johnson,MD,MPH, Chair (Brigham& Women'sHospital)
○ Joseph R. Betancourt, MD, MPH (Harvard Medical School, Massachusetts
General Hospital)
○ HaroldD. Cox (BostonUniversity)
○ Kate Walsh(BostonMedical Center)
○ CeliaWcislo(HealthCare UnionLeader)
○ Manny Lopes(East BostonNeighborhoodHealthCenter)
○ MyechiaMinter-Jordan,MD,MBA (The DimockCenter)
● CIB Leaders:
○ Gerry Thomas:Directorof CommunityInitiativesBureau
○ Huy Nguyen,MD:InterimExecutive DirectorandMedical Director
○ Anne McHugh: Directorof the ChronicDisease PreventionDivision
● Frank MartinezNocito:Departmentof Transitional Assistance
OUR CHALLENGE
Overall, health-promoting resources are unevenly distributed across the city of Boston,
followingpatternsof racial segregationandpovertyconcentration(30).
● Blacks, Asians, Latinos, and Public Housing Residents residing in Boston consume (on
average) fewerfruitsandvegetablesperday.
● These same populations experience higher rates of asthma, type 2 diabetes,
hypertension,andobesity,comparedtotheirwhite counterparts
For our project, we faced the challenge of food insecurity among “threshold populations” which
do nothave reliable accesstoaffordable andnutritiousfood.Inourprojectwe:
● Consideredthe issueof racial justice andhealthequityasitappliedtofoodinsecurity:
25. 25
○ BPHC distinguishes between health disparities (differences) and health inequities
(unfairness). We considered the structural forces, such as racism that play a role in
populationhealthoutcomes.
○ The jurisdiction of BPHC is the entire city of Boston. The neighborhoods vary
depending on health status, racial/ethnic makeup, income level, education level,
etc. We targeted our recommendations to the community/population we were
taskedto serve.
○ We incorporated the social determinants of health equity framework. Racism drives
access to social determinants (housing, education, living conditions, etc.), which
thenaffects healthoutcomesof a population.
Political Considerations
With the recent shift in Boston leadership with a new city council and mayor, the primary
focuses in the area of public health have been homelessness and substance abuse. While these
efforts should not go unnoticed, little consideration has been placed on food access initiatives.
One challenge thatBPHCmay face will be toestablishpolitical will toaddressthispopulation.
Population WeTargeted
BPHC serves all neighborhoods, especially those affected by racial/ethnic disparities, such as
Roxbury, North Dorchester, South Dorchester, Mattapan, and Hyde Park. The threshold
population lives particularlyin low-income communities, butis spread throughout the entire city
of Boston.
Income
The income of the threshold population exceeds federal poverty level. However, the federal
poverty level does not take into account the high cost of living in Boston. There is no set national
or state standard income cut-off forthispopulation.
OtherRelevant Information
As the process for applying to federal food assistance benefits went viral over the last year and
half, the system of matching case managers with clients became an online process. As the
Department of Transitional Assistance worked out the kinks in the new system, many
beneficiaries lost their benefits as well as new applicants, or those trying to renew. Because of
this, we know that the threshold populationin Boston has increased over the last year and a half
because once beneficiaries lose access to their benefits, they potentially enter into the
thresholdpopulation.
28. 28
Percentage of HouseholdswithEarnings under $30,000 inBoston, MA
LOGISTICS
Site Contacts
● Nicole Ferraro: Wellness Coordinator for BPHC Chronic Disease Prevention and Control
Division
● Felipe Ruiz:PICHCommunityChange Coordinator
Barriers We May Encounter
Currently, very little is known about the threshold population. We researched the “threshold”
populations in Boston, or those individuals and families that have a yearly income just high
enough to not qualify for existing benefits that would alleviate food insecurity, but who
continue to feel vulnerable and struggle to maintain access to healthy, affordable foods in
Boston. One of our concrete deliverables will be to define this population.
29. 29
APPENDIX B: LITERATURE REVIEW
Introduction
Foodinsecurityreferstoaninabilitytoaccessenoughfoodtomaintainanactive,healthylifeat
all times(1).A greatnumberof Americansfindthemselvesinthisfoodinsecure category;in
2014, 14% of US householdsexperiencedadecrease inmeal size andafeelingof hungerdue to
an inabilitytoaffordadequate,nutritiousmeals(1).Foodinsecurityisassociatedwithadverse
healthoutcomes,includingcardiovasculardisease anddiabetes inadultsandmental healthand
developmental delaysinchildren(2).
Many programs exist, both nationally and in Boston, to help low-income residents meet their
basic needs, including access to nutritious food. These programs include federal food assistance
programs, such as the Supplemental Nutritional Assistance Program (SNAP), Women, Infants,
and Children (WIC), and Temporary Assistance for Needy Families (TANF). The goal of food
assistance programs is to reduce food insecurity throughout the US amongst the individuals with
the greatestfinancial need.
To qualify for these federal assistance programs, individuals and households must meet a set of
income and work guidelines. For SNAP, the federal income limit is “a gross monthly income that
is at or below 133% of the federal poverty line” (2). This means a single-person household
cannot receive benefits if an individual’s gross monthly income is greater than $1,276. Table 1
belowillustratesthe federal definitionof 133% of povertyforhouseholdsof differentsizes.
Table 1: Federal Definition of 133% of poverty (2)
HouseholdSize Grossmonthly income
(130% of poverty)
Netmonthly income
(100% of poverty)
1 $1,276 $ 981
2 1,726 1,328
3 2,177 1,675
4 2,628 2,021
5 3,078 2,368
6 3,529 2,715
7 3,980 3,061
8 4,430 3,408
Each additional member +451 +347
Although food assistance programs, like SNAP, are meant to help those most in need, they
neglect to provide assistance to vulnerable populations with gross monthly incomes that are
above the defined cutoff. The federal standards incorrectly assume that the cost of living is the
same across the entire US, and do not account for the high cost of living in cities such as Boston.
This effectively disqualifies individuals with an income greater than 133% from accessing the
food assistance services that they need. Nationally, 26% of food-insecure individuals live at
185% of the povertyline,meaningtheyare ineligible formostfoodassistance programs.
30. 30
In Boston, the livable wage for a single-person household is $13.77 an hour, or a gross monthly
income of $2,203 (3). In order for an individual to live comfortably and cover all basic needs in
Boston (i.e. food, housing, healthcare), he/she would need to earn nearly $1,000 more per
month than the amount designated by the SNAP eligibility criteria. Due to the high cost of living,
a significant portion of Boston’s population falls into a “threshold” income category, meaning
they earn too much to participate in SNAP and other federal and state food assistance
programs,yetstill struggle toputfoodon the table.
The threshold population is undoubtedly a public health concern, yet little is known about the
characteristics or extent of the problem. In light of the relative novelty of the threshold
population concept, this review aims to uncover the extent of the problem and what steps are
beingtakentoaddressitin the US.
Methods
We searchedseveral onlinedatabasesforpeer-reviewedjournals.Thesedatabasesincluded
PubMed,BU LibrariesSearch,andGoogle Scholar.We usedkeysearchterms,suchas “food
insecurity”and“hunger”pairedwith“SNAP”or“federal assistance.”Othersearchterms
included“SNAPutilization,”“hunger,”“rootcausesof hunger,”“hungerindex,”“hungry
populations,”“Bostonfoodinsecure,”“foodinitiatives,”“cityhungerprograms,”“addressing
foodinsecurity,”and“livablewage.” Since the term“thresholdpopulation”wascoinedby
BPHC, we were notable to searchusingthisterm.In fact,verylittle literature existswhich
discussesthe specificdefinitionandneedsof the thresholdpopulation. Of the peer-reviewed
articles,we includedonlythose publishedwithinthe last10years.We excludedanyarticlesnot
publishedinEnglish.We alsoexcludedarticlesrelatingtoglobal orinternationalfoodinsecurity
issues.
We alsoperformedaWebsearch forgreyliterature andprogramwebsitespertainingto
thresholdpopulations.The same searchtermswere employed.We includedall information
foundonfederal orstate websites(i.e.USDA,CDC,MDPH) andsourcesproducedby
organizationsknownforproducingreputable foodaccessdata(i.e.FeedingAmerica,the Food
ResourcesandActionCenter).
Results
We foundnosourcesdirectlyrelatedtothresholdpopulations.The termisclearlynovel,asno
one has writtenorpublishedaboutit.We foundpeer-reviewedarticlesandreportsrelatingto
issuesof foodinsecurity,SNAP,andthe barriersassociatedwith accessingSNAP.We found
evidence of several citywideinitiativestotargetgeneral insecurity.Manyof these were focused
on foodsystemsimprovementthroughurbanagriculture,whichwasnotrelevanttoour
researchquestion,sowe excludedthesefromourreview.We foundevidence of several other
bestpractices.
31. 31
Food insecurityin Massachusettsand Boston
In 2013, there were 375,695 foodinsecure householdsinMassachusetts(10.6% of total
Massachusettshouseholds) (4).The rate of foodinsecurityis comparativelyhigherinBoston
proper;in2014, 14.5% of Boston householdsreportedthatthey have experiencedtimeswhen
theydidnot have enoughmoneytobuyfoodinthe past year (5).In 2014, the rate of overall
foodinsecurityinSuffolkCounty(the countywhereBostonislocated) was15.8%.In the same
year,18.1% of childrenwere foundtobe foodinsecure (6).
SNAPUtilization Rates
Of the 51 millioneligible forSNAP,only43millionparticipatedinthe program in2013 (84% of
total).Thismeans that16% of SNAP-eligibleindividuals,orthose whoare foodinsecure and
qualifyforfederal benefits, didnotutilizethisresource (7).Individualswiththe lowestincomes
are more likelyto participate in SNAPthanthose whoare eligible,buthave higherincomes.
Only41% of eligible elderlyadults(60+) receivedSNAPbenefitsin2013 (7). Otherpopulations
withlowutilizationratesincludethose withahouseholdincome abovethe povertyline (42%
utilizationrate) andlegal immigrants(64% utilizationrate) (7).
Barriers to Accessing SNAP
A reportby the Foodand ActionCenter(FRAC) citesSNAP’slongapplication andburdensome
verificationrequirementsasbarriers toaccessingSNAP.Additionalobstacles include perceived
stigmaof beingabeneficiary,language barriers,andimmigrants’fearthattheywill lose legal
statusif theyutilize the resource (8).BestpracticestoaddressbarrierstoSNAPaccessinclude
wavingface-to-faceinterviewsandraisingawarenessaboutthe amountof benefitsfamiliescan
receive whentheyenroll (8).
AnecdotalEvidence
The thresholdpopulationisanational issue,withmanyfallinginthe “donuthole”between
beingcoveredbyfederal assistance programsandbeingable tofullysupportthemselves.Below
are several excerptsfromstoriesfoundonInternetmessage boards.Theseanecdotesclearly
illustrate anassociationbetweenbeingineligible forSNAP,yetstill experiencinghunger.
“I wason food stamps,gota dollarraise and made40 overthe gross.I left there crying
wondering howIwasgoing to feed my kids. I had no homephone,no cell phone,no
cable, living atthe very minimaland then go outto the roomand peopleon expensive
phonesand niceclothes, nice cars.The lady at thefood stamp officeeven told me a car
wasn'ta necessity.Howdid sheget to work?They really need to reformthe program.If
car insuranceis mandatory then why isn'tthatcounted?Oh thatis right we live in the
horseand buggy era!I wonderhow they gettheir figureson whatAmericanscan really
live off of?”(9)
“Recently, I tried to getfood stampsand they said I madetoo much.I work40 hoursa
weekand get paid $10.00 an hour.I amnot even close to rich and more on the
struggling side.I justam curioushow they can figure I madetoo much?If I wasn'ttrying
32. 32
my hardestand justdidn't havea job would they be more willing to help me if I was
unmotivated?ThepeopleI see thatcan work,butchoosenotto seem to alwaysbeable
to get thehelp they need. I amnottrying to scam thesystemat all. Just a hard-working
mother...any suggestions?”(10)
“These days,many families"fall through thecracks"becausethey try to earn a living,
and still need some governmentaid;which they often don'tgetbecauseof the "tangled
web"of imposed bureaucracy.Thepity is thatthere is still plenty of food to go around”
(11).
Best Practices
We foundnobestpracticesspecificallypertainingtothe thresholdpopulation.We did,
however,find several practicesthatcan be usedto identifyandtrackbothSNAP-eligible and
thresholdpopulations.The practicesare bestclassifiedas:
(1) Screeningtools
(2) Citywide foodaccessinitiatives
Screening Tools
We foundevidence of twoeffectivefoodinsecurityscreeningtools:the WECARE screeningtool
and the Children’sHealthWatch/HungerVitalSign(CHW/HVS).Bothof these toolsare
administeredinclinical settings.
WE CARE assesseswhethermothersatcommunityhealthcentersinPhiladelphia,PA are in
needof basicservices,suchaschildcare,housing,employment,education,foodsecurity,and
heatneeds.Physiciansrefermotherswhoscreenpositive tothe appropriate community
resources.A randomized-control trial foundthatmotherswhowere screened withthe WECARE
tool were more likelytoenroll inanew communityservice at the 12-monthfollow-upvisit,
comparedto motherswhowere notscreenedusingthe WECARE tool.The studyalsofound
that WE CARE mothershad a greaterlikelihoodof beingemployedandreceivingadequate
childcare services,ascomparedtonon-WECARE mothers.Additionally,the investigatorsfound
that WE CARE motherswere lesslikelythannon-WECAREmotherstobe livingina homeless
shelteratthe 12-month follow-upvisit.The authors concluded thatusingascreeningtool and
havingdoctorsmake referralsforsocial determinantsof healthduringwell-childvisits
encouragesfamiliestotake advantage of existingcommunityresources(12). Thisscreeningtool
isa low-cost,holisticmethodthatlinksneedyfamiliestoexistingcommunityresources,and
improvestheirutilizationrates.Thistool isabestpractice because itgoesbeyondjustscreening
for foodinsecurity,butrathergainsinsightintothe wholeindividualandacknowledgeshis/her
multiple basicneedsthatare necessarytosurvive andthrive.
The CHW/HVS is a screeningtool createdbythe Children’sHealthWatch(CHW) network.CHW
isa networkof pediatricians,publichealthresearchers,andchildren’shealth andpolicyexperts
that strive toimprove children’shealthnationally.The networkcollectsreal-timedatainurban
33. 33
hospitalstoassessandaddresseconomichardshipsfacedbyfamilieswithchildren.Thisdatais
thenusedto motivate policy-makerstouptake evidence-basedpolicies(13).
The CHW/HVS isa two-questionscreeningtool thatwascreatedusingthe US HouseholdFood
SecurityScale.Thistool ismeantto identifychildrenlivinginhouseholdsthatare at riskof food
insecurity.The HVSiscurrentlyinuse at several hospitalsnationwide,includingthe Addison
GilbertandBeverlyHospitalsof LaheyHealthandBostonMedical Center(BMC) in
Massachusetts.InBeverly,patientsinthe emergencyroomare screenedforfoodinsecurity.
Those whoare identifiedasfoodinsecure receive abagof nutritiousfoodsfromthe hospitals’
PrescriptionFoodBagprogram.At BMC, the HVS isincorporatedintothe hospital’selectronic
medical record.Patientsthatare identifiedasfoodinsecure are referredtoBMC’sPreventive
FoodPantry (14).
CitywideFood AccessInitiatives
Many citieshave developedfoodaccessinitiatives thattangentiallyaddressthe threshold
population,andcouldbe adaptedtofitthe unique needsof the Bostoncommunity.These
initiativestake amultidisciplinaryapproachtoreducingratesof foodinsecurityinurbanareas.
These foodaccesscoalitionsgenerallyworktoimprove accesstohealthyfoodsin
neighborhoodswithlimitedfoodoutlets.
In Philadelphia,the Anti-HungerSubcommittee isworkingtoassistthe 180,000 Philadelphia
residentswhoqualifyforSNAP,butare notparticipatinginthe program(15). A productof the
Anti-HungerSubcommittee isthe PhillyFoodFinder,whichisafoodresource toolkitthat
consolidatesinformationabouthowtogetaffordable,healthyfoodinPhiladelphia.Thistool is
an interactive,onlinemap.The toolkitprovidesdetailedinformationonapplyingforSNAPand
othernutritionassistance programsthathelplow-incomefamilies buyfoodatthe grocerystore.
Users of the toolkitare able to filtertheirsearchesbasedonwhetherafoodresource requiresa
photoID, proof of permanentresidence,orwhetherthe resource acceptsSNAP.
In a similarvein,the Baltimore CityInitiative wascreatedin2008 to addressfoodinsecurity
issuesinBaltimore.Thisinitiativeispredicatedonthe CommunityFoodServicesModel
designedbyJohnsHopkinstoimprove foodsystemsatthe communitylevel,ratherthantarget
individuals.Thisinitiativeisacollaborationbetweenthe Office of Sustainability,the Baltimore
CityHealthDepartment,the Office of Planning,andthe CenterforaLivable Future (16).
Since the Baltimore CityInitiativebeganin2008, there have beenmanychangesinBaltimore’s
foodaccess landscape.Forone,there have beenmajorchangestozoning.Thisresultedinthe
creationof the Vacants to Value program, where vacantlotsare convertedtogardensand
leasedtoresidentsfor$100 a year(16). The Baltimore CityInitiativehasalsodone agreat deal
to change school lunches.Theyhave implementedprogramssuchas“Get FreshBaltimore”and
Days of Taste” (farm-to-table,nutritional EDprograms) toprovide studentswithhealthymeals
34. 34
each day.The City InitiativehasformedapartnershipwithWashingtonDC’sCentral Kitchen
(DCCK) toprovide these school lunches(17).
Similartothe PhillyFoodFinder,the Baltimore CityInitiative hascreatedaninteractivemap
where Baltimore residentscango tofindout aboutthe food resourcesavailable intheir
communities.Aspartof the greaterfoodaccessinitiative,the BaltimoreCityHealthDepartment
has implementedtheirownprogram, called“Baltimarket.”Thisprogramincludesavirtual
supermarketwhere Baltimore residentscanordergroceriesata local libraryor school and have
themdeliveredtoanaccessible location.Thisprogramhasan addedfinancial incentive;first
time shoppersreceivea$10 bonusto spendonhealthyfoods.Shoppersalsoreceive $10to
spendonhealthyfoodsonsix otheroccasionsthroughoutthe year(18).
Discussion
While we foundnoliterature specificallymentioningthresholdpopulations,there issignificant
evidence inthe foodinsecurityliteraturetodemonstrate thatagreat need existsamongthe
thresholdpopulation.
The general trendintargetingfoodinsecurityseemstobe totake a multidisciplinaryapproach
and to increase the utilizationof existingcommunityresources.Boston,like manyothercities,
has a plethoraof existingfoodaccessinitiatives.These range fromemergencyfoodpantriesand
soupkitchenstofoodrescue programslike Lovin’Spoonfulsandfooddeliveryprograms,suchas
Mealson WheelsandCommunityServings(19,20, 21). Althoughidentifyingthe threshold
populationmaytake some time andeffort,itisimperativethatexistingprogramsbe made
highlyvisible andaccessible inthe meantime.
Similarly,the literatureshowedageneral consensusthatSNAPutilizationratesare low.While
those whoare eligible forSNAPare notnecessarilywithinthe threshold,itisstill concerning
that those whocan receive these resourcesare notreceivingthemdue tofrustrationsand
stigmaassociatedwiththe SNAPapplicationprocess.BPHCmustworkwiththe cityand
statewide partnerstoreduce the burdenof these barriers.
It isoverwhelmingclearthatpovertyandlivablewagesplayacritical role indeterminingwho
fallswithinthe thresholdpopulation.ThisisparticularlysalientinBoston,where the livable
wage isconsiderablyhigherthaninmanyotherplacesthroughoutthe country.It isimportantto
take thisfact intoconsiderationwhenattemptingtoidentifyandtargetthe threshold
population.
35. 35
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December2015]. Available from:http://www.ers.usda.gov/publications/err- economic-
research- report/err194.aspx.
(2) SeligmanH,Laraia B, Kushel M.FoodInsecurityIsAssociatedwithChronicDisease
amongLow-Income NHANESParticipants.Journal of Nutrition.2009;140(2):304-310.
(3) Livingwage.mit.edu.LivingWage Calculator - LivingWage CalculationforSuffolkCounty,
Massachusetts[Internet].2015 [cited13 December2015]. Available from:
http://livingwage.mit.edu/counties/25025.
(4) Projectbread.org.[Internet].2015 [cited14 December2015]. Available from:
http://www.projectbread.org/get-the-facts/reports-and-studies/images/ma-food-
insecurity-has.jpg.
(5) FRAC.FoodHardship[Internet].2015 [cited14 December2015]. Availablefrom:
http://frac.org/pdf/food_hardship_2014.pdf.
(6) Map the Meal Gap | FeedingAmerica[Internet].FeedingAmerica.2015 [cited2015 Nov
30]. Available from:
http://map.feedingamerica.org/county/2013/child/massachusetts/county/suffolk.
(7) USDA. TrendsinSupplemental NutritionAssistance ProgramParticipationRates:Fiscal
Year 2010 to Fiscal Year 2013 [Internet].2015 [cited2015 Nov28]. Available from:
http://www.fns.usda.gov/sites/default/files/ops/Trends2010-2013.pdf
(8) FRAC.Barriersto SNAPUtilization[Internet].2015 [cited14 December2015]. Available
from:http://frac.org/wp-content/uploads/2009/09/fspaccess.pdf.
(9) Toluna- Opinionsforall.Imake toomuch moneytoqualifyforfoodstamps,butI can't
AFFORDto buygroceries.[Internet].2015 [cited13 December2015]. Availablefrom:
https://us.toluna.com/opinions/755524/I-make-too-much-money-to-qualify-for-food-
stamps,-but-I.
(10) Answers.yahoo.com.HowdoImake too much forFood Stamps?[Internet].2015 [cited
13 December2015]. Available from:
https://answers.yahoo.com/question/index?qid=20070523081546AAPna2i.
(11) Avvo.com.Iam gettingdeclinedFoodstampsandMedicare [Internet].2015 [cited14
December2015]. Available from: http://www.avvo.com/legal-answers/i-am-getting-
declined-food-stamps-and-medicare--be-2061524.html.
(12) Garg A,Toy S, TripodisY,SilversteinM,FreemanE.Addressingsocial determinantsof
healthat well childcare visits:aclusterRCT.Pediatrics[Internet].2015 Feb 1 [cited
2015 Nov28];135(2):e296–304. Available from:
http://pediatrics.aappublications.org/content/135/2/e296.
(13)Children'sHealthWatch.WhoWe Are - Children'sHealthWatch[Internet].2015 [cited
14 December2015]. Available from: http://www.childrenshealthwatch.org/about/who-
we-are/.
(14)The Hunger Vital SignTM- Children’sHealthWatch[Internet].Children’sHealthWatch.
2015 [cited2015 Nov 29]. Available from: http://www.childrenshealthwatch.org/public-
policy/hunger-vital-sign/.
(15)PhillyFoodFinder[Internet].PhiladelphiaFood PolicyAdvisoryCouncil.[cited2015 Nov
29]. Available from: http://www.phillyfoodfinder.org/about.
36. 36
(16)Archive.baltimorecity.gov.Planning/Baltimore FoodPolicyInitiative [Internet].2015
[cited14 December2015]. Availablefrom:
http://archive.baltimorecity.gov/Government/AgenciesDepartments/Planning/Baltimor
eFoodPolicyInitiative.as
(17)Dccentralkitchen.org.HealthySchoolFood[Internet].2015 [cited14 December2015].
Available from:http://www.dccentralkitchen.org/schoolfood/.
(18)Baltimarket- Accessto healthyandaffordable foodsinBaltimore [Internet].
Baltimarket.2015 [cited2015 Dec 1]. Availablefrom: http://www.baltimarket.org/.
(19) Cityofboston.gov.ElderlyNutritionServices[Internet].2015 [cited14 December2015].
Available from:http://www.cityofboston.gov/elderly/healthfitness.asp.
(20) Lovinspoonfulsinc.org.Mission|Lovin'Spoonfuls[Internet].2015 [cited14 December
2015]. Available from: http://lovinspoonfulsinc.org/what-we-do/our-mission/.
(21)CommunityServings[Internet].2015 [cited14 December2015]. Available from:
http://www.servings.org/index.cfm.
(22)Kushel MB,Gupta R, Gee L, Haas JS.Housinginstabilityandfoodinsecurityasbarriersto
healthcare among low-incomeAmericans.JGenInternMed.2006;21(1):71–7.
(23)GundersenC.Foodinsecurityisanongoingnational concern.AdvNutr.2013;4(1):36–
41.
(24)GundersenC,Elaine W,EngelhardE,Del Vecchio T, SatohA. Map the Meal Gap 2012
Highlightsof Findings.FeedAm.2012;501(c):1–29.
(25)ChildrenYUS,CookJT, BlackM, ChiltonM,Cutts D, HeerenTC,etal. Are FoodInsecurity’
s HealthImpactsUnderestimatedinthe U.S.Population?Marginal FoodSecurity Also
PredictsAdverse HealthOutcomesinYoungU.S.ChildrenandMothers.AdvNutr.
2013;4:51–61.
(26)FoodA, HealthP.RX for HealthyChildDevelopment :2012;
(27)Frank D a, BuitragoM, VorembergA.FoodInsecurityamongChildreninMassachusetts.
2013;25(1).
(28)Scope P. Hungerand FoodSecurityinAmerica :2014;(July).
(29)Mabli J, OhlsJ. SupplementalNutritionAssistance ProgramParticipationIsAssociated
withan Increase inHouseholdFoodSecurityinaNational.jjournal Nutr.2015;145:344–
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(30)DammannKW, SmithC. Race,homelessness,andotherenvironmental factors
associatedwiththe food-purchasingbehaviorof low-income women.JAmDietAssoc
[Internet].ElsevierInc.;2010;110(9):1351–6. Available from:
http://dx.doi.org/10.1016/j.jada.2010.06.007.
(31)PearsonN,Biddle SJ,GorelyT.Familycorrelatesof fruitandvegetableconsumptionin
childrenandadolescents:asystematicreview.PublicHealthNutr[Internet].
2009;12(02):267. Availablefrom:
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(32)ShannonN.Zenk,AmyJ. Schulz,Srimathi Kannan,Laurie L.Lachance,GracielaMentz,
WilliamRidella.NeighborhoodRetail FoodEnvironmentandFruitand
VegetablenIntakeinaMultiethnicUrbanPopulation.AmJHeal Promot.
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(33)Ratcliffe C, McKernanSM, Zhang S.How much doesthe supplemental nutrition
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(34)Mayer VL,HillierA,BachhuberMa., LongJ a. Food Insecurity,NeighborhoodFood
Access,andFood Assistance inPhiladelphia.JUrbanHeal [Internet].2014;91(6):1087–
97. Available from:http://link.springer.com/10.1007/s11524-014-9887-2.
(35)EdinK, BoydM, Mabli J, OhlsJ,WorthingtonJ,Greene S,et al.SNAPFoodSecurityIn-
DepthInterviewStudy,Final Report.2013;(March):NutitionAssistance ProgramReport
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39. 39
APPENDIX D: LIST OF PERSONS CONTACTED
Stakeholder Organization Sector
Frank MartinezNocito Departmentof Transitional
Assistance
Government
EmilyShea BostonElderlyCommission Government
JenniferObadia,PhD TuftsFriedmanSchool of Nutrition Academia
Stephanie Ettingerde Cuba,MPH Children’sHealthWatch Academia
Parke Wilde,PhD TuftsFriedmanSchool of Nutrition Academia
SuttonKiplinger The Food Project CommunityOrganization
Fredi Shonkoff The DailyTable Community Organization
RonnGarry Jr. Tropical Foods CommunityOrganization
40. 40
APPENDIX D1: STAKEHOLDER INTERVIEW QUESTIONS
When completing the stakeholder interviews, we tailored our interview questions to each
person based on experience and knowledge of the threshold population. However, we
developed several key questions that we asked in each interview to gain a sense of the
individual’s knowledge of the threshold population and of the current climate of food insecurity
inBoston.
Theme I: Current Climate of Food AccessPrograms and Food Insecurityin Boston, MA
▪ What is the main population that you serve? How would you describe the needs of your
community?
▪ What communitiesdoyouthinkare mostaffectedwithfoodaccessissuesinBoston?
▪ What do you see as the mainchallenge tofoodaccessissuestodayinthe cityof Boston?
▪ What do you think about the current programs that address food security in Boston? Do
theyfitthe needsof the populationwhoare foodinsecure?
▪ How effectively do you think programs like SNAP address food insecurity, especially in
Boston?
Theme II: “Threshold” Populations:BestPractices, Suggestions/Recommendations
▪ What is your understanding and knowledge of “threshold” populations in Boston, and what
are root causes?Do youthinkthataddressing“threshold”populationsisanurgentissue?
▪ Can you comment on some of the best practices or methodologies being used in other cities
to identify,access,ortrack thispopulation?
▪ Do you currently address the “threshold” population in your agency or program? If yes, how
so?
▪ Do you have any suggestions for how we can track the “threshold” population? How could
we determine eligibility,andhow wouldwe accessthemforfuture interventions?
▪ If you could envision an intervention that targeted the “threshold” population, what would
that interventionlooklike?
▪ Who or what could hinder this project from coming into realization? What political
blockagesmightwe face?
41. 41
APPENDIX D2: STAKEHOLDER ANALYSISTABLE
Stakeholder
(n=8)
Potential
Target Populations
Root Causes of
Food Insecurity
Database and Criteria
Recommendations
Insights
Government
(n=2)
People who are denied from SNAP
or not accessingtheresource
Seniors ineligiblefor SNAP or
receive lowest level of benefits
Wage/income Databases:
Greater Boston Food Bank
Project Bread
Criteria:
Livablewage: Elder Economic
Security Standard as upper
limit
System changes at the state level
affecting benefits/ application process
SNAP outreach, enrollment, and
retention is necessary
Pair initiativesto capture all vulnerable
populations
Academia
(n=3)
People who register but don’t
qualify for federal benefits
Seniors/Elderly
Undocumented immigrants
Formerly incarcerated
Low income working class
Seasonal workers
Screened patients in primary care
and emergency department
Wage/income
Poverty
Geographical proximity
Databases:
Children’s Health Watch and
Hunger Vital Sign
DTA: SNAP data
Project Bread FoodSource
Hotline
BMC Food Pantry
Criteria:
Housing: HousingCostBurden
LivingWage: City Ordinance
Food Assistance:DTA
Need a clear definition of subgroup in
order to access them
Incorporateeconomic equality into any
initiative
Streamliningscreen tools is essential
Anti-poverty must be an aspectto
address insecurity amongthreshold
Low income working population needs
incentive to maintain jobs
HVS is best practiceatwell child visits
Community
(n=3)
Low income area pediatric clinics
Dudley Square neighborhood
Low income working class
Low income working women
Wage/income
Geographical proximity
Perceptions of priceof
healthy food
Transportation
Databases:
DTA data
Project Bread
Zip codes of clients accessing
elective food initiatives
Criteria:
LivableWage >133% of the
poverty line
Must define threshold population before
you can solvethe issue
Need transition programs for those
coming off SNAP
Important to incentivizeworkers
Importance of dignity when target food
insecure
Hire within vulnerablecommunities to
providejobs/ economic boost
Obesity concern as outcome of hunger
Obstacles includeshiftin gov’t focus
43. 43
APPENDIX E1: COMPOSITE DATA ACCESS – HOW TO ACCESS DATABASES
Database
Name
Data Storage
Unit
Publicly
Available
Data Access Channel Documents Access Fee Contact Person Resource Links
Children’s
Health
Watch:
Hunger Vital
Sign
EPIC @
Boston
Medical
Center
No BMC, BUMC, or BUSPH
Clinical with IRB/HIPPA
approval
Clinical WarehouseData
Access
Clinical Data Warehouse Request
Form:
http://www.bumc.bu.edu/ocr/clinical
-research-clinical-warehouse-data-
access/clinical-data-warehouse-
request-form/
Yes Linda Rosen,
Clinical Data Warehouse
Research Manager
lirosen@bu.edu
http://www.bu
mc.bu.edu/ocr
/clinical-
research-
clinical-
warehouse-
data-access/
BMC Food
Pantry
EPIC @
Boston
Medical
Center
No BMC, BUMC, or BUSPH
Clinical with IRB/HIPPA
approval
Clinical WarehouseData
Access
Clinical Data Warehouse Request
Form:http://www.bumc.bu.edu/ocr/
clinical-research-clinical-warehouse-
data-access/clinical-data-warehouse-
request-form/
Yes Linda Rosen,
Clinical Data Warehouse
Research Manager
lirosen@bu.edu
http://www.bu
mc.bu.edu/ocr
/clinical-
research-
clinical-
warehouse-
data-access/
Greater
Boston Food
Bank
Greater
Boston Food
Bank
Yes Hunger in America (HIA)
Study Data
2014 Results:
http://www.gbfb.org/our-
mission/hunger.php
Executive Summary:
http://www.gbfb.org/perch/resource
s/hia2014localexecsummaryfinal-
1.pdf
Prevalence data:
http://gbfb.org/news/2014/greater-
boston-food-bank-feeding-america-
survey-focuses-on-hunger-food-
insecurity-in-eastern-
massachusetts.php
No Jonathan Tetrault,
Senior Manager of
Community Initiatives
jtetrault@gbfb.org
Adriene Worthington, Senior
Manager of Nutrition
aworthington@gbfb.org
Project Bread
FoodSource
Hotline
Project Bread No MOU between BPHC and
Project Bread
Annual Report 2012:
http://support.projectbread.org/site/
DocServer/2012_PB_Annual_Report.
pdf?docID=8061
TBD Maria Infante,
Director of Community
Outreach
maria_infante@projectbread.
org
http://www.pr
ojectbread.org/
get-help/food-
source-hotline-
2012.pdf
44. 44
APPENDIX E2: COMPOSITE DATA ACCESS – HOW TO ACCESS CRITERIA
Criteria
Name
Criteria Storage Unit Publicly
Available
Criteria Access Channel Documents Access
Fee
Contact Person Resource Links
Livable
Wage
U.S. Census
Bureau
IRS
City of Boston
Yes Income statistics:U.S.
Census Bureau
SOI (Statistics of Income)
Tax Stats: IRS
City of Boston Employee
Earnings Data
Household Survey Income Data
Reports (U.S. Census Bureau):
http://www.census.gov/hhes/www/inc
ome/
Individual Income Tax Return Data
(SOI):
https://www.irs.gov/uac/SOI-Tax-Stats-
Individual-Income-Tax-Returns
https://www.irs.gov/uac/SOI-Tax-Stats-
Individual-Income-Tax-Returns-
Publication-1304-(Complete-Report)
City of Boston Employee Earnings
Report:
https://data.cityofboston.gov/Finance/
Employee-Earnings-Report-2014/4swk-
wcg8
No N/A See Documents Tab
Affordable
Housing
United States
Department of
Housingand
Urban
Development
Yes HousingAffordability
Data System (HADS):
Metro American Survey
Data
Metro American Survey Datasets:
http://www.huduser.gov/portal/datase
ts/hads/hads.html
No N/A http://portal.hud.gov/
hudportal/HUD?src=/
program_offices/com
m_planning/affordabl
ehousing/
Food
Assistance
Department of
Transitional
Assistance
No MOU between BPHC and
DTA
SNAP datasets
WIC datasets
TANF datasets
TBD Frank Martinez Nocito,
Assistant Director of
SNAP Nutrition Education
Frank.MartinezNocito@m
assmail.state.ma.us
N/A
45. 45
APPENDIX E3: CLINICALDATA WAREHOUSE DATA REQUEST FORM
Research Privacy Application
Preparatory to Research
Name:
Degree(s):
Academic Title:
Email address:
Phone Number:
Study Title/Study Idea:
IRB Protocol #:
Department:
Section:
Expertise:
eRA Commons ID:
CTSI will support some data requeststhat are for translational research. Please consider the following
questions:
A. Is the work funded by a grant?: Yes ___ No ___
If the answer to question A is no, please continue with section B. Otherwise, please scroll down to the
next page.
B. Will the requested data be applied to any of the following areas?
1. The transfer of new understandings of disease mechanisms gained in the laboratory into the
development of new methods for diagnosis, therapy, and prevention and their first testing in
humans; Yes ___ No___
2. The translation of results from clinical studies into everyday clinical practice and health
decision making; Yes ___ No____
3. The discovery of ways to move clinical findings into the daily care of patients; Yes___ No ____
4. The movement of scientific knowledge into the public sector and therebychanging people’s
everyday lives. Yes___ No ____
46. 46
C. If translational and unfunded, then CTSI will pay for the first 8 hours of work towards this data
request. Yes___ No ___
How will you pay for the services? ____________________________
Internal Boston University funds (via journal entry)
Boston Medical Center funds
Evans Medical Foundation funds
Other
i. Please supply the email address to which the bill for the Clinical Data Warehouse services
($60/hour) should be sent? Note that there is no charge for requests that take less than 1
hour. Email:_____________________________
ii. Investigators may ask for an exemption to being charged by providing a brief written
justification here which will be reviewed by the Office of Clinical Research. These will be
considered for trainees (students, residents, fellows) and unfunded (faculty) research. Other
justifications may be considered.
<please add justification here>
The Privacy Rule(45 CFR 164.512) allows theuse or disclosureof protected health information required in
order to prepare a research application or proposal,provided thatcertain criteria aremet. Pleaseread the
followingstatements. If you agree, pleasesign below. Also complete item #4.
1. The use or disclosurerequested will belimited to the preparation of a research protocol or for
similar purposes preparatory to research.
2. No protected health information will beremoved from the covered entity by the researcher in
the courseof the review.
3. The requested information constitutes the minimum necessary data to accomplish the goals of
the research.
4. Pleaseattach a listof the selection criteria for records required (e.g.; all asthmatics seen in the
Asthma Clinic),the dates of the records required (e.g.; clinicvisitsfromJuly 1,1998 through December 31
2000),and data fields required for the research.
By submitting this form with an INSPIR application, the PI attests to the following:
I declarethat the requested information constitutes the minimum necessary data to accomplish thegoals
of the research.
I agree that the protected health information will notbe re-used or disclosed to any other person or
entity, except as required by law,for the authorized oversight of the research study, or for other research
for which the use or disclosureof protected health information would be permitted by the Privacy
Regulation (45 CFR 164.512)
47. 47
DATA AND/OR RECORDS NEEDED FOR RESEARCH PROTOCOL
1. Selection Criteria (e.g.; asthmatics seen is Asthma Clinic)
2. Dates of required records:from ___/___/___ through ___/___/___
3. Data fields required (listfields required from an electronic data base,or listfields to be recorded
from the paper record by the researcher)
48. 48
APPENDIX E4: BMC DATA WAREHOUSECHARGES FOR ACCESS
BostonMedical CenterData Warehouse ChargesforAccessingDataforResearchPurposes
Q: Where do the charges go andwhyare there chargesfor thisservice?
A: The funds go to pay for the service (of accessing the Clinical Data Warehouse for research
purposes). Boston Medical Center has invested in the creation and maintenance of the
warehouse. Funds collected for accessing data for research purposes are not used for
warehouse operations. They are used to expand and maintain services for investigators to be
able to easilyaccessthese dataforresearchpurposes.
Q: What are the charges for accessing data for research purposes from the Boston Medical
CenterClinical DataWarehouse?
A: $70 per hour. Users are charged when the service takes 1 hour or more. Researchers are
encouraged to include these costs in grant proposal budgets as either a service, consultation, or
as percent full time equivalent (FTE) for the data warehouse manager, as appropriate. See table
belowforapproximate costsforsome commontypesof datarequests.
Q: How are data requestchargesdeterminedandbilledfor?
A: Researchers are encouraged to request an estimate of effort anticipated. Having a well-
defined request from you will enable us to estimate your costs more accurately and will shorten
the time needed to complete requests. When the work is done, the warehouse manager
preparesaninvoice foryouor your departmenttopay.
Q: Can data be accessedatno charge?
A: Investigators wanting to access data from the data warehouse for research purposes may ask
for an exemption to being charged by providing a brief written justification which will be
reviewed by the Office of Clinical Research. These will be considered for trainees (students,
residents,fellows) andunfunded(faculty) research. Otherjustificationsmaybe considered.
49. 49
APPENDIX E4: BMC DATA WAREHOUSECHARGES FOR ACCESS(CONTINUED)
Sample ResearchQuestionsandEstimatesof Time/ChargetoAnswerThem
Type of request Question/requestexample Time/charge
Simple counts(the answer
isa number).
How manypatientswithasthmain calendar
year2007 had an emergencydepartment
visitat BMC? How manypatientswith
pneumoniawere admittedtothe MICU in
2007?
< 1 hour/no
charge.Not all
countswill be any
charge.
Complex count(the
answerisa number,but
selectioncriteriacomplex)
How manyadulttrauma patientsdeveloped
nosocomial pneumoniainthe ICUin
CY2007?
1-<2 hours
(~$70)
Simple datasetgenerated
basedon fewclearcriteria
or listprovidedby
investigator(the answeris
a dataset).
Please provide acompletemedicationlist
for 100 patients(listprovidedby
researcher). Pleaseprovidealistof
patientswithcholesterol >240 mg/dl who
were seeninthe primarycare clinicin2007.
2-3 hours
($140-$210)
More complex datasetand
source of data inthe
warehouse (the answeris
a dataset).
Please provide resultsfor20 specified
laboratorytestsandcomplete problemlists
for a listof patients.
8-12 hours
($560-$840)
Explorationanddefinition
of a datasetwithuncertain
properties(the answerisa
dataset,afterseveral
iterationstobetterdefine
sample selectioncriteria
and explorationof free
textfields).
Please identifypatientswhoare pregnant
and have cervical smearsshowingcervical
intraepithelial neoplasiaIIandhave hada
generalizedseizure
40 hours or more
(>$2,800)
Note: Recurrent or repeated requests for the same type of data may take less time and
therefore be lesscostlythanthe firstrequestwhendone againone ormore times.
53. 53
APPENDIX G: HEALTH EQUITY IMPACT ASSESSMENT
In order to ensure that the programs and policies geared toward the threshold population in Boston are
equitable, we suggest that Boston Public Health Commission follow the guidelines developed by
Brandeis University’s Heller School for Social Policy and Management program, “Diversity Data Kids.”
Health equity impact assessments allow for a thorough analysis of a program or policy before it is
implemented, with the goal of ensuring equitable delivery of healthcare services. Diversity Data Kids
discussesthe keyelementstopolicyequityassessment:
I. Logic
To best evaluate a program’s efficacy, it is best to understand the problem that the program aims to
address, the specific goals of the program, and how the program is designed to achieve these goals. This
first phase of the health equity impact assessment evaluates the program’s design by identifying
principle components, the resources needed to carry our those components, and the performance
objectives. A logic model is the best method to conceptually map out these program components, and
will allow BPHC to specifically analyze the program through a health equity framework to assess the
impactit wouldhave ondisadvantagedcommunitiesinBoston (32).
II. Capacity
The second phase of the health equity impact assessment evaluates the capacity of the program to
address equity. Capacity is the ability of a future program to fulfill the specific goals that it has outlined,
as well as the ability of the program’s resources to address the outcomes for the target population.
Assessing the capacity of a program will determine whether the program has the program components
necessary to deliver equitable services to the threshold population in Boston in a way that is consistent
withwhathas beenassessedinthe logicsection (33).
III. Research Evidence
When designing public health initiatives for Boston, it is essential that the programs be strongly
grounded in evidence, so as to determine whether it will effectively help vulnerable families improve
their health outcomes. In order to ensure that there is sufficient research evidence to target health
initiatives equitably,BPHCmustconsiderthe followingquestions:
▪ What works?
▪ What worksfor whom?
▪ What worksunderwhatconditions?
While the first question can be answered through a general body of research effectiveness, a thorough
examination of the logic and capacity of other programs must be considered to gain a larger program
contextandbestcomplete apolicyequityassessment(34).
