In 1972, Congress enacted the Nutrition Act under Title VII of the Older Americans Act in order to initiate a new national policy which would provide older Americans, particularly those with low incomes, with nutritionally sound meals served in strategically located community centers. There is little evidence that Title VII outreach efforts actually identifies, informs, and persuades the neediest elderly to participate. This paper identifies some of the significant personal, environmental, and programmatic barriers to effective outreach that exist today. Policy and program recommendations are proposed to overcome the negative impact of these barriers.

Robert L. Schneider, DSW1

In January, 1968, Congress appropriated $2 million for the establishment of a three year national demonstration and research program of nutrition for older people to be conducted by the Administration on Aging under the Title VI (Research and Development) provision of the Older Americans Act (Bechill & Wolgamot, 1972). The primary reason for this action was found in the results of a mid-60s nationwide study of malnutrition (National Study on Food Consumption and Dietary Level) that produced the shocking evidence that 95 million Americans, approximately 50% of the population, did not consume an adequate diet (USDA, 1966). Subsequent analysis of the study revealed that between 6 and 8 million persons over 60 years of age also had deficient diets. During the same period, practitioners in programs for the elderly were consistently identifying malnutrition, or problems of nutrition, as a major concern of the elderly (Segal, 1970). Staff of the Administration on Aging provided the following statement of purpose for the national demonstration program: The primary purpose of the nutrition program is to design appropriate ways for the delivery of food services which enable older persons to enjoy adequate, palatable meals that supply essential nutrients needed to maintain good health. Purposes that are an integral part of the program are the opportunities for socializing with friends and companions, participation in leisure-time activities, consumer and nutri-

'Asst. Dean, School of Social Work, Virginia Commonwealth Univ., 901 W. Franklin St., Richmond, VA 23284.

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tion education, and counseling and assistance in utilizing other community resources. The specific objective of the food and nutrition program is to study and demonstrate methods of providing appetizing and nutritionally adequate meals in settings conducive to eating and social interaction with peers (Cain, 1976).

All demonstration projects were required to include at least five basic elements: (1) the provision of meals in group settings or on a homedelivered basis; (2) nutrition education and information; (3) systematic evaluation; (4) the provision of support services; and (5) outreach services. Utilization of older persons for staffing purposes was also stressed (Cain, 1976). Based on the findings of these demonstration projects, Public Law #258, The Nutrition Act, Title VII (Older Americans Act) — Nutrition Programs for the Elderly, was signed into law on March 22,1972. The Act summarizes the results of the demonstration project in its statement of rationale: Many elderly persons do not eat adequately because: (1) they cannot afford to do so; (2) they lack the skills to select and prepare nourishing and well-balanced meals; (3) they have limited mobility which may impair their capacity to shop or cook for themselves; and (4) they have feelings of rejection and loneliness which obliterate the incentive necessary to eat a meal alone. The purpose of this nutrition program was to initiate a new national policy which provides older Americans, particularly those with low incomes, with low-cost, nutritionally sound


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Barriers to Effective Outreach in Title VII Nutrition Programs

goals that are difficult to measure such as "better health" or "living with dignity." There is little evidence that outreach, a major component of the Act, actually brought in and retained as clients, the neediest of the needy, the isolated, and the most thoroughly malnourished. Cain (1976) notes that it appears to be much more tempting to collect data on costs and efficiency criteria than on those factors for which the program ostensibly was established. A study Each project will provide meals in a congregate by Pelcovits (1971) reported that nutrition programs starting from scratch, while attracting setting. Each congregate meal site established by the many participants, experienced considerable project must provide at least one hot meal per difficulty in reaching isolated, needy older day, five or more days a week, and any addition- citizens. al hot or cold meals which the project may elect A question was raised by Bechill & Wolgamot to provide. (1972) as to what extent the various nutrition Each meal served must contain at least one-third projects actually reached a significant proporof the currently recommended dietary allowtion of elderly persons who were, in fact, social ly ances. Home delivered meals will be provided where isolated. Virtually two-thirds of all participants in the national demonstration projects reported necessary and feasible. Each recipient of a grant or contract must pro- they were active in their communities and had a vide for comprehensive and on-going outreach variety of social contacts. These findings suggest activities from each congregate meal site to that virtually all projects could have benefited assure that the maximum number of the hard-to- from having a more aggressive program of outreach target group of eligible individuals particireach from their inception. A study by Research pate in the nutrition project. Opinion Corporation for the Administration on Provide an opportunity to evaluate the effectiveAging (1975) found that a great majority of nutriness, feasibility, and cost of each project. Include such training as necessary to enable the tion sites filled their bugeted numbers of meals personnel to carry out the provisions of the Title. within a short time subsequent to funding withProvide special menus, where feasible and out significant outreach efforts to locate needy appropriate, to meet particular dietary needs. elderly. Outreach efforts often became attempts Furnish a site for such nutrition projects in as to follow-up on drop outs from the program and close proximity to the majority of eligible indi- not to recruit those elderly who were seriously vidual residents as feasible, and where appropri- malnourished or isolated. ate, to furnish transportation (Cain, 1976; Guide, Administration on Aging staff were aware of 1973). the difficulties of effective outreach as reflected in a draft copy of program goals for Title VII in June, 1973:

meals served in strategically located centers such as schools, churches, community centers, senior citizen centers, and other publ ic or private nonprofit institutions where they could obtain other social and rehabilitative services (Publication 258, 1972). In addition, the following excerpts from the Act further describe the basic requirements of all nutrition programs: •

• • •

• • • •

The Question of Effectiveness and Outreach 3

"Of all the efforts this country (USA) has conceived to make the lives of our elderly more comfortable and more meaningful, few have had more impact than the hot lunches served in and by the community" (Percy, 1974). However, Cain (1976) indicates that "the multiple purposes cited in the Nutrition Act signal complications for the evaluative researcher" in determining the overall program impact. In other words, an investigation of the effectiveness of the Act is a complex task due to ambiguous

'Outreach may be defined as that effort needed to locate, inform and persuade persons to become participants in a given program, including any special assistance which meets their particular needs (Reed, 1971).

Goal 5: Assure that those elderly most in need, primarily the low income minorities and the isolated can and do participate in nutrition services by providing an extensive and personalized outreach program and transportation service. Evaluation data indicate that a more vigorous and personalized outreach campaign is needed to assure that priorities are met (Cain, 1976). An attempt has been made to assist in assessing nutrition program outreach through identifying barriers to outreach. Their identification and an examination of their impact on planning and programming, suggest initial steps to promote outreach services that may be successful in


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reaching those most in need of nutritional assistance.

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accessability of the program. Three outreach workers reported another dimension of fear when they believed that their own safety was imperiled, such as visits to danProgram Analysis and Interviews gerous neighborhoods, working alone at night This study is based upon the following data: or in suspicious apartment buildings. When the (a) analysis of an intensive Title VII outreach outreach workers feared for their physical wellprogram in Planning District #15, Virginia; and being or perceived that they were potentially at (b) interviews with directors of 15 Title VII nutririsk, they reported that they became less willing tion programs throughout Virginia. to search out the isolated persons who needed During the Summer of 1977, a coordinator assistance. and eight outreach workers undertook an intenFour outreach workers and three Title VII dirsive outreach effort in Planning District #15 in ectors also identified fear as an impediment Virginia in order to identify more eligible particiwhen older persons who were initially reluctant pants for the District Title VII nutrition programs. to speak to them or to answer the door later Outcomes of this effort were mixed despite a reported that they believed a stranger would vigorous and highly individualized campaign. attempt to harm them, rob them, or assess their Study data was gathered through semi-structured home for future crime. In most instances, efforts interviews with eight outreach workers and 15 to provide these individuals with information Title VII directors and participant observation or to determine their eligibility could not even by the author. Although respondents from both be initiated. urban and rural settings provided significant The age of the outreach worker appeared to be data through brief answers to specific questions, a variable that impeded as well as facilitated outan open-ended, exploratory item also yielded reach, although more precise study would be important data on the effectiveness of agency required to confirm the extent of particular cirand individual outreach efforts. cumstances. Seven younger outreach workers (24 to 30 years of age) reported that several older persons were reluctant to speak with them or to Barriers Identified Findings revealed that there were many bar- sustain a conversation. This reluctance appeared riers that impeded the effectiveness of Title VII to be based on a generalized mistrust of young outreach efforts. In order to systemically present people, or discomfort in speaking to a different these findings to practitioners and researchers, generation. For other older persons, it was a a three-part framework that illustrates the major pleasure to talk with a young person and did not dimensions of the barriers to effective outreach impede the workers' outreach effort. Seven was designed. These dimensions are: personal, Title VII directors who reported that older outreach workers (50 to 60 years of age) are more environmental, and programmatic. readily accepted by their peers, also indicated Personal factors. — Personal factors refer to these workers had more difficulty in coping with individual characteristics or bio-psychosocial the exhaustive efforts required to cover large dimensions that are attributed to either an elderly geographic or rural areas, and to coordinate all person or an outreach worker. These character- the required logistical arrangements. istics are designated personal primarily because these behaviors, attitudes or reactions which Environmental factors. — Environmental obstruct effective outreach are found within the factors refers to those attitudes, opinions, culindividual or a small group of individuals. tural practices, or regional beliefs that are held One of the primary barriers to effective out- by the society or region at large which often reach identified by six outreach workers and six influence the beliefs and attitudes of older resiTitle VII directors was fear. They reported that dents and outreach workers. fear was usually expressed by older persons as All eight outreach workers and six Title VII a belief that physical or spiritual harm would directors reported that racism or racial prejudice befall them outside the confines of their present was often a significant barrier to effective outliving pattern. To adventure outside in order to reach efforts. In some cases, an older person attend a nutrition program raised their level of would refrain from speaking to an outreach fear to the point that they preferred to remain at worker who was of another race about the prohome regardless of information, persuasion, or gram. In other instances, the location of the

Programmatic factors. — Programmatic factors describes elements of Title VII programs and procedures that impede the outreach process. Because Title VII is fairly complex and be^ cause a similar nutrition program has never been attempted before, policies and procedures have been developed that influence and change the delivery of nutritional services. Special scrutiny and evaluation must be continued in order to assess their impact on the target population. All eight outreach workers and six Title VII directors reported that determination of eligibility according to the four criteria in the Act was a

very serious barrier to outreach. The difficulty reported was in using very imprecise eligibility guidelines (e.g., how does one readily determine if older persons have "feelings of rejection or loneliness which obliterate the incentive to prepare a meal and eat alone," or how should the outreach worker question individuals in order to test their "knowledge to select and prepare well balanced and nourishing meals?") It was acknowledged that outreach workers who visited the home or apartment of an elderly person must make judgements that would be difficult under the best of circumstances. Six outreach workers reported that the selection of a rent-free meal site location without a thorough survey of the surrounding elderly population was a barrier to outreach efforts. Failure to pre-screen potential tracts for truly needy elderly before site selection often resulted in hours of outreach that were not fruitful because the residents were ineligible, or in discovering thatthe neediest individuals lived great distances from the proposed site. Five outreach workers and seven Title VII directors stated that the use of conventional media such as TV, radio, newspapers, appearances before clubs and organizations, and flyers was not sufficient to reach many of the neediest. Although considerable publicity was generated around a given program, the respondents indicated that traditional media were not effective in reaching the socially isolated and needy individuals. These media worked more successfully in reaching the better educated and more prosperous individuals. Inadequate transportation to nutrition sites was also reported as a barrier by six outreach workers and nine Title VII directors. Reported problems centered on the unavailability of appropriate vehicles and the lack of coordination between drivers, site administrators, and elderly riders. Many times a new participant was forgotten or overlooked in the planning of bus/van routes. Special physical handicaps presented mounting and dismounting problems for which regular vans were not designed. In some cases, long exhausting rides returning participants to their homes discouraged individuals who did not want to spend excessive time riding a van or bus. Six Title VII directors reported that state and federal privacy and confidentiality laws prevented public health, social service, and Social Security bureaus from providing names and information on needy elderly to nutrition out-


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feeding site was identified with one racial background, and many older persons of another race would not attend the meal or activities. The use of a church for a feeding site was an impediment according to five outreach workers and three Title VII directors. When the site location of a congregate meal was a particular denomination or sect, members of other churches would often not attend. Loyalty to one sect or interdenominational rivalry were hypothesized as possible reasons. Other related comments revealed that when church meal sites provided religious activities, there was a subtle pressure for all to participate. Some church meal sites attempted to provide nutrition services primarily to their own congregants and did not search out other needy individuals. Ten Title VII directors stated that the alleged stigma of participating in a government program also deterred eligible persons from participating. The Title VII program was not perceived as an entitlement but as "welfare," and many older persons who take pride in their individualism and self-determination feared that they would become a burden on society by using this program. Potential participants did not want to call attention to their own problems and tried to remain inconspicuous. There were many older individuals, according to five Title VII directors, who were isolated or cut off from the mainstream of society and its institutions. These were individuals who had no other families with whom they were in contact, who were found sleeping in warehouses or on park benches, who traveled with shopping bags, or who lived in single hotel rooms. Because they were so removed from family and community networks, almost no one knew about them or their whereabouts. The directors indicated this group was the most needy and yet the most difficult to locate.

Implications and Recommendations

Although comprehensive solutions appear to be very remote, the following program and policy recommendations are suggested in order to overcome the negative impact which these identified barriers have on Title VII outreach programs: (1) In order to determine the location of a meal site, Title VII program staff should first conduct a thorough investigation of targeted neighborhoods. Absolute reliance on census data for population characteristics is not recommended because of inaccuracies and outdated information. An offer of a rent-free building for the meal site is also an insufficient reason for selection without a careful survey of the surrounding population. A brief survey consists of overview obtained through general observation of housing conditions, apparent income level, family composition, and neighborhood makeup. In addition, staff should walk through randomly selected streets and talk with community residents about eligible elderly participants. This coupled with data from planning agencies there should provide better evidence on the potential elderly population which may constitute the universe from which participants will be drawn and to

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which outreach may be directed, as well as providing the basis for establishing an eventual meal site. (2) Outreach workers should be organized in pairs or partners, and depending on local demography, the pairings should reflect appropriate combinations of race, sex, and age because these factors facilitiate the recruitment of new elderly participants. The trust or credibility required to persuade someone to join a nutrition program must begin with the initial contact. If an older person can more easily identify with at least one of the outreach workers because of similarities of sex, age, or race, then a greater likelihood of participation is established. (3) Although a study by the Opinion Research Corporation (1975) found that a high frequency of church attendance was a positive indicator for participation by the elderly in nutrition programs, Title VII staff are urged to consider carefully a decision to establish a meal site on church premises. The likelihood of limited participation appears greater at church sites due to interdenominational rivalry, pressures to participate in religious services, and racial prejudice than in a more neutral community site location. However, churches can be invaluable resources for identifying potential participants and informing families and individuals of the benefits of the nutrition program. (4) Representatives from the Administration on Aging and other units of HEW should develop cooperative agreements so that outreach efforts could readily utilize the existing comprehensive network of information and mailings that already exist such as Social Security. With proper supervision, confidentiality and privacy laws would not be compromised. Since the goal of providing services is the same for all agencies, cooperative procedures and policies could be enacted by which relevant departments could use existing data while safeguarding individual rights. (5) At present, many outreach workers either ignore the eligibility criteria required by the Nutrition Act or spend considerable time evaluating the presence or absence of valid indicators of eligibility. Little effort by the Administration on Aging has been made to define or clarify the criteria so that outreach workers can more efficiently judge the status of individuals and their possible participation. The most bothersome criteria is #4 which states that individuals would be eligible if "they have feelings of rejection or loneliness that obi iterate their incentive to eat adequately." It is recommended that this


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reach efforts. The directors believed that use of already existing resources would have greatly increased their outreach capability. Five outreach workers and eight Title VII directors reported that limited staffs prevented effective follow-up and further searching for larger numbers of potential participants. Extensive time was required to develop a trusting relationship with older persons and consequently, the workers could not expand the territory to be covered or interview sizable numbers of persons. In rural areas, great distances and the remote location of many elderly poor compounded the problems of staffing and time. Six outreach workers and seven Title VII directors reported that the site coordinators became obstacles to effective outreach when they failed to: (1) follow up on individuals who had expressed interest; (2) welcome new participants warmly; (3) provide scheduled activities including meals on time; or (4) coordinate the transportation system with a newly interested person. At the same time, it was acknowledged that the site coordinator position required high levels of skill in working with people, organizing groups, coordinating programs and record keeping.


Bechill, W. D., & Wolgamot, I. Nutrition for the elderly: The program highlights of research and development nutrition projects funded under Title VII of the Older American Act of 1965, June, 1968 and June, 1971. AoA, DHEW Publ. No. SRS 73-20236, Washington, DC, 1972. Cain, L. D. Evaluative research and nutrition programs for the elderly. (DHEW Publ. #OHD 77-20120), Washington, DC, 1976. Opinion Research Corporation. An evaluation of outreach of the nutrition program for the elderly. Prepared for AoA, Princeton, NJ, Dec, 1975. Guide to effective project operations: The nutrition program for the elderly. Administration on Aging, Washington, DC, April, 1973. Pelcovits, J. Nutrition for older Americans. Journal of the American Dietetic Association, 1971,58, 17-21. Percy, C. Crowing old in the country of the young. McGrawHill, New York, 1974. Publication 258 — 92nd Congress, 2nd Session, S1163, USGPO, Washington, DC, March 22, 1972. Reaching out: A working guide to performing outreach for the senior citizen. SEVAMP Senior Services, Norfolk, VA, 1975. Reed, L. H. SAMS (Serve A Meal to Seniors) Project. Curtis Park Community Ctr., Inc., Denver, 1971. Segal, J. A. Food for the hungry: The reluctant society. The Johns Hopkins Press, Baltimore, 1970. U.S. Dept. of Agriculture. Task force report on nutrition and adequate diet. (Unpubl. Memorandum), 1966.

Remaining Questions The study also raised questions for future investigations: • What information and systems of dissemination are most appropriate to inform the truly isolated elderly? • What effect does the presence or absence of supporting social services offered at the site have on regular attendance? • How can program benefits be presented to the elderly without the stigma of poverty or welfare? • What system of follow-up is most effective in maintaining the participation of hard-to-reach elderly? Answers to these and other questions tru ly wi 11 assist the leadership and staff of Title VII programs in providing the elderly with the nutritional resources available to them.


"Health is a state of physical, mental and social well-being, and not merely the absence of disease and infirmity." -World Health Organization edited by Geral Dene Burdman

A S p e C t S Ruth M. Brewer,




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U A ^ ^ ^ A l l ^ problems as the aging process, aging and mental health, maintenance of health, community health, demographic trends, research and its implications. 255 pp. Price $12. Please prepay orders under $15. Continuing Education Publications PO Box 1491 Portland, Oregon 97207 (503) 229-4873

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criterion be eliminated because it demands evaluation of a subjective state of mind. Highly trained psychological experts have never claimed great success in these evaluations and lesser skilled outreach workers should not be asked to do more. (6) Because the role of the meal site coordinator is pivotal for the successful implementation of an outreach program, particular attention must be given to recruitment and training. Persons with skills in organizing and coordinating individuals in small groups, program planning, and directing community activities should be sought for employment. Further training that emphasizes an understanding of the purpose and intent of Title VII programs, the importance of positive relations with community agencies, the relationship between an efficient transportation system and attendance at meals, and techniques to help new participants overcome fear and feelings of stigma is highly recommended. (7) In order to find and serve the most needy elderly, programs must more readily accept the elderly person who will not participate on a regular basis but who will drop by for a meal from time to time. Some elderly have developed a life style that will not be changed. If they are transient and difficult to locate, it seems to be what they prefer. Consequently, less emphasis should be placed on regular attendance. Warm welcomes, friendly service, and an open invitation to return should be encouraged among staff. Statistical accounting could be developed to reflect this level of participation.

Barriers to effective outreach in Title VII nutrition programs.

In 1972, Congress enacted the Nutrition Act under Title VII of the Older Americans Act in order to initiate a new national policy which would provide...
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